Income-Qualified Rebate Application

Income-Qualified Rebate Application
Name*

First NameLast Name
Email*
example@example.com
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Year Built Square Feet
Do you own or rent?*

OwnRent

Income Verification
Main Income
Other Income

Home Type*

Single Family ExistingManufactured ExistingMulti-Family

Existing Heating & Cooling System*

ZonalForced Air Furnace with Central AirForced Air Furnace without Central AirOther

Efficiency Measure*

Conventional Heat Pump InstallationSingle Head Ductless Heat PumpHeat Pump Water HeaterDuct SealingEnergy Storm WindowsInsulationOther

Serviced Area
Total Square Feet

Please make check payable to*

MemberContractor

Contractor Name

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

YesNo

Signature* Member Signature
Signature*

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Date*

MonthDayYear
Date
Should be Empty: