This program is sponsored by National Grid. You must be a Rhode Island residential electric customer of National Grid to qualify for the offer contained within this form. This rebate offer is available to all Rhode Island residential electric customers of National Grid and may be subject to change without prior notice. This rebate may not be combined with any other National Grid offer. National Grid reserves the right to conduct field inspections to verify installations. Limitation of liability: National Grid does not guarantee the performance of installed equipment expressly or implicitly. Customer agrees that the Energy Efficiency Program Provider (EEPP) has the unilateral right to apply for any ISO-NE capacity payments or environmental credits resulting from this energy efficiency project, and agrees not to file for such payments or credits either directly or indirectly. Manufacturer and/or retailer agree to provide the EEPP with such further documen-tation as the EEPP may request to confirm the EEPP’s ownership of such benefits. For more information, Call 1-877-711-3013 or visit www.smartenergy-zone.com/nationalgridri.

(!) IMPORTANT: Photocopy your entire submission for your records. You could be required to mail these photocopies.

*First Name *Last Name

*Installation Address

*City *State *Zip Code

Email (Used to send status updates regarding this application.) Phone

*National Grid Electric Account #*Denotes Required Field

Own Rent New home Existing home Primary residence Vacation home

Single family Condo/Townhouse Multifamily ____ # of units________________________________________________

Type of home (check one in each section):

*Manufacturer Name *Model

*Purchase Date

Valid for purchases made from 01/01/2012 to 12/31/2012. Rebate requests must be postmarked by 01/31/2013.

Mailing Address (*Required If different from above) City State Zip Code

*Store Name

ENERGY STAR® Qualified Refrigerator & Freezer Rebate

$50

Limit one refrigerator and one freezer rebate per Rhode Island residential National Grid electric account per calendar year.

Eligible refrigerator or freezer must be installed in Rhode Island.

Refrigerator must be 7.75 cu. ft. or larger to be eligible. Excludes compact models.

Call 1-877-886-2539 or visit powerofaction.com/ri for a complete list of participating appliance retailers.

To receive your rebate check by mail, follow these steps:1) Purchase an ENERGY STAR® Qualified Refrigerator or Freezer and install in a property with an active meter using Rhode Island residential National Grid electric services.

2) Make a copy of the first page of your most recent electric bill.

3) Mail the following to the address below. This application, completed accurately and legibly. A copy of your most recent electric bill. A copy of your receipt reflecting the qualifying purchase and date.

Typical Annual Savings from Replacing an Old Refrigerator or Freezer with an ENERGY STAR® Qualified Model of Equal Size

Appliance Type

ChestFreezer

Pre-1993 1993-2000 2001-2008

$300

250

200

150

100

50

$0Top FreezerRefrigerator

Bottom FreezerRefrigerator

Side-by-SideRefrigerator

Purchase Year

ENERGY STAR Refrigerator/Freezer Rebate (RI)Offer# H043000PO Box 130013

El Paso, TX 88513-0013

GDZ