MI PROPANE WATER HEATER REBATE APPLICATION

2. Consumer/Applicant Information

(where rebate will be mailed)
First and Last Name*
Address*

Address

Street Address Line 2

CityState

Postal / Zip Code
Phone *
Email
example@example.com
Propane Supplier*
How did you learn about the rebate?*

OnlineInstaller/BuilderMy Propane RetailerOther
Note: Checks not cashed within 90 days will expire and will not be reissued. Allow 4-6 weeks for rebate checks to be processed.

3. Licensed Water Heater Installer Information
First and Last Name*
License #*
Company*
Company Address*

Address

Street Address Line 2

CityState

Postal / Zip Code
Phone *
Company Email*
example@example.com

4. Propane Safety Inspection Information

(Can be Preformed by a Licensed Installer or Propane Supplier.)
A Safety inspection accompanying the installation of the qualifying appliance(s) must include one or more of the following 1) a leak test; 2) a pressure test if required by applicable laws, rules and regulations, and/or 3) a flow and lock up test on the regulator(s The Safety inspection must be performed prior to the submission of any rebate application. The purpose of the Safety inspection is to support the Commission Rebate Program rules and requirements that a safety inspection did occur as required under the rebate program rules and regulations. Licensed contractors can perform safety inspections. DO NOT INCLUDE A COPY OF THE SAFETY INSPECTION
Safety leak check was performed:*

YesNo
Date*

MonthDayYear
Date
Technician Name*
Pressure test was performed:*

YesNo
Date*

MonthDayYear
Date
Technician Name*
Flow & lock-up test was performed:*

YesNo
Date*

MonthDayYear
Date
Technician Name*
Who Preformed the Safety Inspection?*

Performed by Licensed InstallerPerformed by Propane Company
Safety Inspection Company*
Address*

Street Address

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

5. Signature & Upload

(Signatures and Upload Proof of Energy Star and Invoice/Receipt of Purchase)
I certify that this propane appliance was purchased for installation at the above address. I am aware that copies of completed inspection forms (leak check, pressure test, or flow and lock up test) and a receipt of purchase is required at the time of submission of the rebate form in order for the rebate to be accepted for review. I am further aware that no check will be issued until all program requirements have been met and the rebate has been approved. I understand, and have complied with all laws, rules and regulations governing the installation of the qualifying appliance(s) and with the manufacturer’s installation instructions. The Michigan Propane Commission assumes no responsibility whatsoever for the installation, inspection or testing of the qualifying appliance or any associated gas system and, by issuing a rebate, makes no representation, warranty or guarantee regarding the qualifying appliance or the associated gas system. The Commission disclaims any liability for personal injury, property damage, business losses or other damages of any nature whatsoever, whether special, indirect, consequential or compensatory, directly or indirectly arising from the installation of the qualifying appliance. All rebates are subject to availability. This is a limited offer and all requests will be processed on a first-come, first-serve basis. The Commission has first rights on interpretation of all terms and conditions pertaining to this offer.
Customer Signature*

Clear
Date*

MonthDayYear
Date
Safety Inspector Signature*

Clear
Date*

MonthDayYear
Date
By signing above you agree that you complied with all laws, rules, and regulations governing the installation of the qualifying appliance(s) and with the manufacturer’s installation instructions. If you disagree, please share your explanation on a separate sheet of paper.
Upload Proof of Energy Star, Invoice/Receipt of Purchase, and/or Propane Work Order (if applicable)*

Proof of Energy Star can be found on the unit as an Energy Guide/Label or with the documentation booklet that comes with the new unit.
Cancelof
Checklist of Items to Include:

Applicant InfoLicensed Installer InfoReceipt of PurchaseProof of Energy StarPropane Company Work Order, if available
Application must be submitted, postmarked, emailed or faxed

by December 31, 2024, 11:59pm EST

Return hard-copies to: Michgan Propane Commission

629 W. Hillsdale St., Lansing, MI 48933

mpga@kdafirm.com

Fax: 517.485.9408

Questions? We’re happy to help! Call us at 517.312.0097
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2024 PROPANE APPLIANCE SAFE INSTALLATION REBATE APPLICATION

1. Water Heater Information

2. Consumer/Applicant Information

3. Licensed Water Heater Installer Information

4. Propane Safety Inspection Information

5. Signature & Upload