ATTACH RECEIPT HERE
Appliances
Energy Trust Products l Incentive Application l Form 920C
Want your incentive faster?
Apply online!
Efficiency Requirements
Appliance
Visit www.energytrust.org/appliances
How to apply:
Appliance must qualify at time of
purchase to be eligible.
2 Complete entire application, including:
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Customer Information
Installation Address Information
All Appliance Information
Your signature
An itemized receipt or invoice with:
o
Purchase Date
o
Model Number
o
Price Paid
o
Proof of Payment
If purchased from The Home Depot,
please include the Special Services
Customer Invoice (SSCI) in addition to
the register receipt.
Incentive Amount
Clothes
Washer
MEF of 2.4 – 2.59
$50
MEF of 2.6 or higher
$70
Refrigerator
At least 10% above federal standards
$75
Freezer
At least 10% above federal standards
$35
1 Purchase a qualifying product.
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(Select ENERGY STAR® models
that meet the requirements below)
Additional qualifications may apply; see our website for more details. www.energytrust.org/appliances
Customer Information (Required for payment)
Are you applying as:
Homeowner
Business or Rental
Property Owner*
Renter
*If site is used for rental income or a business, a W-9 is required for payment. If a W-9 is
required the payment will be made to the name on the W-9.
Customer Name
Installation Address
City
State
Zip
Mailing Address for Check
City
State
Zip
3 Submit completed application, and a copy
of the itemized sales receipt via mail, fax or
email within 60 days of purchase.
Energy Trust of Oregon
Products
PO Box 2445
Spokane, WA 99210-2445
1.877.501.9629 fax
products@energytrust.org
Need-to-know information:
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Please allow six to eight weeks for incentive
processing after completed application and
supporting documents are received and
approved.
Missing information will delay payment.
Primary Phone
Home
Work
Cell
Second Phone
Home
Work
Cell
Email Address
Installation Address Information (Required for payment)
Who is your electric utility?
PGE
Pacific Power
Other
NW Natural
Cascade Natural Gas
*
Other
No Gas Service
How do you heat your water?
Electricity
Natural Gas
Who is your gas utility?
Other
Appliance Information (Apply for up to two appliances per application)
Appliance Type
Refrigerator
Freezer
Clothes Washer
Refrigerator
Freezer
Clothes Washer
Manufacturer/Brand
Model Number
Acceptance of Terms and Conditions
By signing below, I certify that all information on this form is true and correct to the best of my knowledge. I represent that I have read, understood
and agreed to the terms and conditions herein. I also agree that Energy Trust may contact my retailer regarding any information that my application
might be missing in order to expedite application processing.
Participant Signature
Measures and Incentives are subject to change.
Form 920C v02 150420 — Page 1 of 2
Date
Appliances
Energy Trust Products l Incentive Application l Form 920C
TERMS AND CONDITIONS
ELIGIBILITY: Incentives are available to Oregon customers
of Portland General Electric, Pacific Power, NW Natural and
Cascade Natural Gas and are payable to the unit owner. If
incentive cannot be paid to the owner, Energy Trust will ask
for proof of conservatorship, relationship or other
documentation prior to releasing incentive to owner’s
representative. Participants who are commercial businesses
or landlords must submit a completed W-9 to receive an
incentive. Participants who have already received an
Energy Trust incentive at time of purchase are not eligible
for an additional incentive on that appliance. All participants
must submit an itemized receipt showing that the appliance
was purchased new. Itemized receipts must be legible and
contain the following information:
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Purchase date
Retailer name
Model number of appliance applied for
Price of appliance applied for
Proof of payment
Completed applications must be submitted within 60 days
from the date of purchase. Applications must be
accompanied by an itemized receipt. If purchased from The
Home Depot, please include the “Special Services
Customer Invoice” (SSCI) in addition to the register receipt.
Incentive offers are subject to funding availability and may
change. Neither Energy Trust nor Ecova shall be
responsible for lost or misdirected mail.
Clothes Washers: Clothes washers must be
ENERGY STAR certified and have an MEF of 2.4 or higher
to be eligible. Clothes washers must be installed in at a site
that heats its water with fuel from Portland General Electric,
Pacific Power, NW Natural or Cascade Natural Gas.
Refrigerators and Freezers: Refrigerators or freezers must
be ENERGY STAR certified and at least 10 percent above
federal standards to qualify. Refrigerators or freezers must
be installed in an Oregon site within Portland General
Electric or Pacific Power service territory.
Energy Trust will refer to the qualified models list posted on
www.energytrust.org/appliances when approving
applications for all appliance types. Energy Trust will not pay
incentives on appliances received due to any of the
following circumstances, including but not limited to:
• Resale, used or refurbished appliances
• Leased or rented appliances
• Appliances received due to a warranty claim, recall or
exchange
• Appliances won as a prize or given as a gift
In no event will incentive amounts equal or exceed the price of
the appliance applied for.
NO ENDORSEMENT: In promoting ENERGY STAR products,
Energy Trust does not endorse any particular manufacturer. The
fact that the names of particular manufacturers, equipment or
systems may appear on applications does not constitute an
endorsement. Manufacturers, contractors, equipment or systems
not mentioned are not implied to be unsuitable or defective in any
way.
TAX LIABILITY: Energy Trust is not responsible for any tax
liability, which may be imposed on the Participant as a result of
payment of any incentives. Energy Trust is not providing tax
advice, and any communication by Energy Trust is not intended or
written to be used, and cannot be used, for the purpose of
avoiding penalties under the Internal Revenue Code.
ENERGY INFORMATION RELEASE: Participant will allow
Energy Trust access to electric and natural gas utility account and
usage information for the physical address of the property in which
the product was installed. Participant agrees to provide other
reasonable assistance to Energy Trust to obtain such information.
Participant also acknowledges that Energy Trust will treat all
information about services provided and participant’s resulting
energy savings as confidential, but may report such information in
the aggregate as part of reports or other documentation regarding
its programs.
DISCLAIMER / NO LIABILITY: Participant understands that, while
Energy Trust is providing funding for the incentives payment,
Energy Trust is not supervising work performed for Participant nor
is Energy Trust responsible in any way for proper product
installation, completion of that work or proper performance of any
product purchased. Energy Trust is simply providing funding to
assist Participant in implementing energy-efficiency measures.
Energy Trust does not guarantee any particular energy-savings
results by its approval of the Application or by any other of its
actions. Energy Trust will not be held responsible for any claims
made by a retailer regarding the amount of the incentive and the
eligibility of the purchase.
Resources
Get your incentive faster, apply online:
www.energytrust.org/appliances
Qualified Products List
www.energytrust.org/appliances
Link to W-9
www.energytrust.org/w9
Get help finding your model #
www.energytrust.org/appliances
Click on the frequently asked questions link
Recycle your old working refrigerator/freezer
www.energytrust.org/fridgerecycling
Contact Us
Email products@energytrust.org.or call 1.877.283.0702
Measures and Incentives are subject to change.
Form 920C v02 150420 — Page 2 of 2