What you will need:

SALES RECEIPT & INSTALLATION INVOICE

A receipt that shows proof of purchase. This program excludes used appliances. Please include installation invoices from the contractor. If self-installed, please select self-install.

APPLIANCE SERIAL NUMBER

The serial and model number for the appliance.Please refer to the manufacturer’s website for more information on where to locate the serial number.

MAIL OR ONLINE APPMail your submission to:Florida City Gas Rebate Offer Dept. 14-90591 P.O. Box 540071 El Paso, TX 88554-0071

Or visit FloridaCityGasRebates.com Customer Information

Florida City Gas Account Number (REQUIRED)Please write the first 10 digits of your account number. Include any leading zeros but do not include dashes.

First Name (as it appears on account) Last Name

Installation Address City State Zip Code

Phone Number Email Address

Rebate Prepaid Card

Make payment to: Account Holder Landlord* Contractor**Assignment of Rebate form required. Please visit FloridaCityGasRebates.com for more information. Payment will only be paid to the account holder with this form.

Mailing Address (if different from above) City State Zip Code

First Name (As it appears on account) Last Name

Applicant Signature Print Name Date

Installation Information SELF INSTALLED. By selecting this box I certify that the equipment was installed at my account address and I agree to a physical inspection to the equipment if necessary

CONTRACTOR: The following contractor installed my Natural Gas appliance:

Contractor Business Name

Contractor Business Address City State Zip Code

License Number

Natural Gas Rebate Application

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Contractor Phone Number

Thank you for your interest in Natural Gas! Qualifying products purchased and installed within one year are eligible for rebates. You must complete Steps 1 through 7 for each rebate application. All fields are required unless otherwise noted.

Rebate application requirement: You must complete ONE rebate application PER appliance.

By signing this form the customer agrees to the terms and conditions.

Member FDIC, pursuant to license by Mastercard Incorporated. No cash

idnight EST the last day of the month of the valid thru

You’ll receive a rebate on a Florida City Gas Prepaid Mastercard. The card is issued by MetaBank®, Member FDIC, pursuant to license by Mastercard International Incorporated. Mastercard is a registered trademark, and the circles design is a trademark of Mastercard International Incorporated. No cash access or recurring payments. Card valid for up to 6 months; unused funds will be forfeited at midnight EST the last day of the month of the valid thru date. Card terms and conditions apply, see MyPrepaidCenter.com/site/Mastercard-promo

What Did You Install?Indicate the appliance type you are seeking a rebate for below and work with your contractor to enter the product information. PLEASE Note: all rebates are UP TO the offered amounts.Check One: Gas to Gas Replacement Electric to Gas Switch Propane to Gas Conversion New Construction

CHOOSE PRODUCT INFORMATIONAppliance Type: (Check One) Tank Water Heater High-efficiency Tank Water Heater Tankless Water Heater

Furnace Gas Range Gas Dryer

Install Date Manufacturer Model Number Serial Number Total Cost

Please provide information on the old equipment that was replaced.

Appliance Type Fuel Source Brand Model Number Serial Number

ELIGIBILITY REQUIREMENTS ■ Please include the cost of the appliance plus the installation in the total cost field above.This program will pay for the cost of the appliance plus the cost of installation, up to the eligible rebate amount.

■ Supporting documentation (installation invoices, sales receipts, etc.) must clearly show thatan electric to gas or a propane gas switch occurred.

■ In order to qualify for the High Efficiency standard tank water heater rebate, the natural gas appliancemust meet the Energy Star certified criteria. For more information, visit EnergyStar.gov.

■ Applications incorrectly marked as high-efficiency will be denied and will require a resubmission. ■ Furnace cannot be a portable or freestanding unit. Space heaters and dual power appliances are not eligible for rebate.

Additional InformationYour answers to these questions are used to evaluate the program, and do not impact your eligibility for, or the amount of, your rebate.

Select the Natural Gas products you currently have installed in your home: Range/Stove Water Heater Furnace/Boiler Generator Grill Clothes Dryer Outdoor Lighting Pool Heater Gas Fireplace Patio Heater

Select any non-gas appliance you currently have installed in your home: Electric Water Heater Electric Air Conditioner Propane Water Heater Electric Heat Pump Electric Dryer Propane Range Electric Range Electric Residential Heat Propane Range

Select where you purchased the appliance you are seeking a rebate for: Appliance Direct Best Buy BrandsMart HHGregg Other Home Depot Jetson Appliances Lowes Sears

How did you hear from us: Radio TV Contractor Online Print Other______________________________

Sales Receipt & Installation InvoiceRemember to submit a copy of the invoice and the receipt (no proposals, quotes or estimates) and must contain:

Installation date Itemized product and/or service description Purchase price For Contractors: Rebate amount deducted off the purchase price, clearly labeled as an energySMART or Florida City Gas rebate and a customer signature

Natural Gas Rebate Application

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