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Application Form for WashWise Clothes Washer Rebate Program

APPLICATIONS WITH MISSING OR INCOMPLETE INFORMATION WILL NOT BE PROCESSED.
Did you remember to:
□ Read the Terms and Conditions?
□ Check that your utility is listed on the back of this page as a participating utility?
□ Complete the application and provide ALL information as it appears on your utility bill?
□ Include a copy of the completed application and provide your itemized receipt?
(Receipt MUST include retailer name, address & phone number, purchase date & price, product make, model,
and quantity purchased)
□ Sign and date rebate application AND payment release authorization (if applicable)?
□ Make a copy of the completed application form and all required documentation to KEEP for your records?
□ Mail the completed application and required documentation with proof of purchase to:
WashWise Clothes Washer Rebate Program
1400 SW 5th Avenue, Suite 700
Portland, OR 97201
For more information and a detailed explanation of the Terms and Conditions, please visit www.washwiserebate.com
or call 1-866-632-4636.

Customer Information (All information below is REQUIRED for processing)

Full Name: Daytime Phone: ( )
(as it appears on utility bill)

Full Installation Address:

City: State: Zip:
Full Mailing Address (if different):
City: State: Zip:
Email Address:
My Electric Utility is: My Water Utility is:
Water Heater Fuel is: □ Electric □ Natural Gas □ Propane
Clothes Dryer Type is: □ Electric □ Natural Gas □ Propane

Product Rebate Information

Date Purchased: Date Installed:
Model Number (required): *Serial Number (required):

*Serial numbers are usually located on the inside of the clothes washer door or on the back of the machine.

Acceptance of Terms and Conditions

I hereby certify that all information is accurate including claims of customer and equipment
information. I have read all terms and conditions on the reverse side of this form and acknowledge
that WashWise may verify all the information provided.

Customer Signature: (Please print rebate form before signing and dating) Date:

This information can be made available on request to accommodate people with disabilities and those who need language assistance.
4170 04/09
Payment Release Authorization
(Complete this section ONLY if payment is to be made to someone other than the participating utility customer.)

I am authorizing this payment of my rebate to the third party [‘Payee’] named below and I understand that I will not be
receiving the rebate check from WashWise. I also understand that my release of the payment to the third party does not
exempt me from the rebate requirements outlined in this application.
Check should be made payable to : (Please print “Payee” name) Telephone number:

Payee mailing address:

Authorized by: (Please print the Participating Utility Customer’s Name and sign) Date:

Terms and Conditions

Please refer to the following terms and conditions prior to signing acceptance on reverse side:

• The clothes washer rebated has been installed at the address indicated above.
• All information supplied on this form is true and correct.
• WashWise staff has permission to verify any of the information on this form, and inspect the
clothes washer installation upon request.
• You have not received a WashWise rebate for this home after January 1, 2002.
• This form must be received by the WashWise program within 90 days of the clothes washer purchase.
• The model number and serial number are required for payment.
• The WashWise rebate program and rebate levels may change without prior notice.
• All information must be complete and a copy of an itemized receipt enclosed to be considered for payment.
• Your rebate check will be mailed within 6-8 weeks of receipt and verification.

Participating utilities have made no implied or express warranties or representations with regard to these
products, energy savings or water savings from these installations. This offer ends December 31, 2009 or
when funds are exhausted.

List of participating utilities:

Puget Sound Energy Snohomish County PUD
● Puget Sound Energy residential electric ● City of Everett
customers only
● Puget Sound Energy gas-only customers Saving Water Partnership
do not qualify unless they are a member ● Cedar River Water and Sewer District
of one of the participating water utilities ● City of Bothell
● City of Duvall
Seattle City Light ● City of Mercer Island
● Coal Creek Utility District
City of Renton ● Highline Water District
Tacoma Power ● Northshore Utility District
● Olympic View Water and Sewer District
Tacoma Water ● Seattle Public Utilities
● Shoreline Water District
Cascade Water Alliance ● Soos Creek Water and Sewer District*
● City of Bellevue ● Water District #20
● City of Issaquah ● Water District #45
● City of Kirkland ● Water District #49
● City of Redmond ● Water District #90
● City of Tukwila ● Water District #119
● Covington Water District ● Water District #125
● Sammamish Plateau Water & Sewer Dist. ● Woodinville Water District
● Skyway Water & Sewer District

City of Bonney Lake

*Note: Must be a water customer, sewer-only
customers do not qualify.
PRINTED ON RECYCLED PAPER.