CUSTOM REBATE WORKSHEET
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Custom Efficiency rebates are for new energy-saving equipment and projects that are
not eligible for a standard rebate. Please provide the information below to help us to
determine your rebate amount.
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Account Name
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Contact Name
Contact Phone Number
2. EQUIPMENT INFORMATION –
Number of Battery Cells
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Operational Information
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In addition to this form, you must submit a completed Custom Rebate Application
(right) with all invoices, receipts, and specification sheets. All Custom Rebate Terms and
Conditions apply. See the Commercial Custom Efficiency Rebate Application for details.
1. CUSTOMER INFORMATION
nt from
differe
B
Battery Rated Amp Hours
Contact E-mail
Valid for retrofit applications only.
C
Charge Cycles per Day
D
Charge Days per Year
E
Charge Time (Hours)
F
% non-charge time with no battery
1.
2.
Existing Charger Information
G
Manufacturer
H
Model
I
J
Type*
Quantity
K
AC Voltage (3-phase)
L
AC Input Amps
1.
2.
*Types: Ferroresonant, SCR, Hybrid, High Frequency
New High Efficiency Charger Information
M
N
Manufacturer
Model
O
P
Type*
Quantity
Q
AC Voltage (3-phase)
R
AC Input Amps
1.
2.
*Type: High Frequency
TEAMING UP TO SAVE YOU MONEY
OFFICE USE ONLY
Date Received________________
Pre-Inspected?
o YES
o
NO
Date________________ Initials__________
Post-Inspected?
o YES
o NO
Date________________ Initials__________
TOTAL REBATE AMOUNT
$
Printed on Recycled Paper
0616