Income-Qualified Rebate Application
Name
*
First Name
Last Name
Email
*
example@example.com
Service Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Year Built
Square Feet
Do you own or rent?
*
Own
Rent
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Income Verification
Main Income
Other Income
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Home Type
*
Single Family Existing
Manufactured Existing
Multi-Family
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Existing Heating & Cooling System
*
Zonal
Forced Air Furnace with Central Air
Forced Air Furnace without Central Air
Other
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Efficiency Measure
*
Conventional Heat Pump Installation
Single Head Ductless Heat Pump
Heat Pump Water Heater
Duct Sealing
Energy Storm Windows
Insulation
Other
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Serviced Area
Total Square Feet
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Please make check payable to
*
Member
Contractor
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Contractor Name
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Your application will not be considered complete until our department has received your supporting documents. Please attest that supporting documents have been sent to verify@bentonrea.org
Yes
No
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Signature
*
Member Signature
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: