OPC PROPANE FURNACE REBATE APPLICATION

2. CONSUMER/APPLICANT INFORMATION

(where rebate will be mailed)
Name*
Address*

Address (where rebate will be mailed)

Street Address Line 2

CityState / Province

Zip
Phone*
Propane Company*
Email
example@example.com
How did you learn about the rebate:*

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

3. LICENSED INSTALLER INFORMATION
Name*
License #*
Company*
Address*

Address

Street Address Line 2

CityState / Province

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

4. PROPANE SAFETY INSPECTION INFORMATION

(can be performed 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 OPC 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. If your installer is not licensed by the state of Ohio, then the Propane Safety Inspection MUST be performed by your propane retailer. DO NOT INCLUDE THE SAFETY INSPECTION REPORT WITH THIS APPLICATION.
Safety Leak Test 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 Performed the Safety Inspection?*

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

Address

Street Address Line 2

CityState

Zip
Email*
example@example.com
Phone*

5. SIGNATURE & UPLOAD

(Signatures and Upload Invoice/Receipt of Purchase)
I certify that this propane appliance was purchased for installation of the above address. I am aware that a receipt of purchase is required of 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 progrom requirements have been met and the rebote has been approved. I understond, and have complied with all lows, rules and regulations governing the installation of the qualifying appliance(s) and with the manufacturer's installation instructions. The Ohio Propone Council 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 OPC disclaims any liability for personal injury, property damage, business losses or other damages of any nature whotsoever 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 served basis. The OPC 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 you have with all lows, rules, and regulations governing the installation of the qualifying appliance(s) and with the manufacturer's installation instructions If you disogree, please share your explanation on a seporate sheet of paper.
Upload Invoice/Receipt of Purchase and Propane Work Order, if applicable*

Cancelof
Application must be postmarked, emailed or faxed by December 31, 2024, 11:59pm EST

Return to: Ohlo Propane Council Rebate Processing

629 W. Hillsdale St., Lansing, MI 48933

opga@kdafirm.com

Fax 517.485.940

Questions? Call 937.203.2322
Checklist of Items to Include:*

Applicant InfoLicensed Installer InfoReceipt of PurchasePropane Company Work Order, if applicable
Should be Empty:

2024 PROPANE FURNACE SAFE INSTALLATION REBATE APPLICATION

1. APPLIANCE INFORMATION

2. CONSUMER/APPLICANT INFORMATION

3. LICENSED INSTALLER INFORMATION

4. PROPANE SAFETY INSPECTION INFORMATION

5. SIGNATURE & UPLOAD