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SGS Small Business* Water Heating Rebate Application NOTICE MUST ATTACH ITEMIZED RECEIPT ENERGY STAR® –listed natural gas equipment qualify for rebates subject to listed maximum: Tanked water heater (≥ .62 EF) … $40.00 Tankless water heater (≥ .82 EF) … $200.00 Limits: ≤ $3,500 in total rebates per business location. Missouri Gas Energy 10 digit account number: ________________ Business name: ___________________________________________________ Contact name: __________________________________________ Physical business address: Street ___________________________________________________________ NAICS 6 digit number_______________ City _____________________________________________________ State ___________________ Zip ___________ Phone _______________________________ E Mail Address _______________________________________________ New Equipment Data with Attached Receipt (required) Date Purchased ___________________ May use back side if more room needed to list equipment installed and replaced. New equipment installed Manufacturer Model Number Rebate Amount $ $ $ Equipment Replaced Equipment replaced Estimated Age of Equipment Manufacturer Model Number Fuel source As a Missouri Gas Energy SGS* natural gas customer: I own my business space I rent/lease my business space did did not influence my purchase decision. This rebate I certify that the above new natural gas appliance/thermostat has been installed in the business listed above. I understand that to receive the rebate, all information requested on this form must be completed AND all purchased related invoices (less than one year old) attached. All installations are subject to inspection in accordance with program approved by MPSC Docket No. GR-2006-0422. I acknowledge MGE’s right to substantiate sales receipts, serial numbers and installation, and to request additional documentation as necessary to assure program criteria compliance. (Rebate cannot be processed without an itemized receipt.) I have read and understand the terms and conditions of the MGE Rebate Program. I certify that the information I have provided is true and correct and the product for which I am requesting a rebate meet the requirements of the Program: __________________________________________________________________________________________________________________________________ Customer Signature Date Is the installer an employee of the business listed above? Yes No Installer name: __________________________________________________________________________________________________________________ Installer address: Street ___________________________________________________________________________________________ City ____________________________________________________ State ___________________ Zip ___________ Work Phone _________________________________ E Mail Address __________________ ______________________ __________________________________________________________________________________________________________________________________ Installer signature: Installer attests that the invoice supplied accurately reflects the date and nature of equipment installed in the customer’s business. Customers mail form to: Missouri Gas Energy, Attn: Rebate Program, 3420 Broadway, Kansas City, MO 64111. DO NOT INCLUDE WITH UTILITY BILL. Applicable rebate will be credited to your natural gas account within 90 DAYS after verification of application and supporting documents. If you have any questions, please e-mail energy.sense@sug.com. *SGS small business is defined as using 10,000 CCF of natural gas or less annually per location.