Rebate Application Form

REBATE APPLICATION AND AGREEMENT

Parties and Program

Applicant Name:

Recitals

WHEREAS, the Rebate Provider operates a rebate program that offers monetary rebates to eligible purchasers in accordance with program rules; and

WHEREAS, Applicant has purchased goods or services that may qualify for a rebate under the Program described below and seeks to apply for payment of a rebate; and

WHEREAS, Provider and Applicant desire to record the terms under which Provider will review, validate, and (if approved) pay the rebate.

Program and Scope of Rebate

Program Name:

Purchase Details

Purchase Date:

Payment Terms

Rebate Amount Requested:

Late Payment Fee (if applicable):

Term and Termination

Program Start Date:

Program End Date:

Confidentiality

All non-public information exchanged between Provider and Applicant concerning this Application and any supporting documentation shall be treated as confidential and used solely for purposes of evaluating and administering the rebate claim. Confidential information shall not include information that (a) is or becomes publicly known through no breach of this Agreement, (b) is rightfully received from a third party without restriction, or (c) is independently developed without use of the confidential information. Each party will use at least reasonable care to protect the other's confidential information.

Certifications and Representations

By submitting this Application, Applicant certifies, represents, and warrants that:

• All information provided is true, complete, and accurate to the best of Applicant's knowledge;
• The purchase claimed was made by Applicant and is not the subject of any other rebate claim under this Program;
• Applicant will provide, upon request, original receipts, invoices, or additional documentation required to verify eligibility;
• Provider may audit or verify claims and may deny or reclaim rebates where material misrepresentation or ineligibility is discovered.

Required Attachments and Attestations

I have attached proof of purchase (receipt or invoice).

I have attached product photos or installation evidence where required.

Governing Law and Entire Agreement

This Application and Agreement shall be governed by and construed in accordance with the laws of the jurisdiction selected below. Any dispute arising under or in connection with this Application shall be exclusively adjudicated in the courts of that jurisdiction.

This document, together with any attachments and the Program rules as incorporated herein, constitutes the entire agreement between Provider and Applicant with respect to the subject matter and supersedes all prior agreements and understandings, whether written or oral.

Applicant Authorization

Applicant authorizes Provider to verify the information provided in this Application with the retailer or third parties, and to use the provided contact information to communicate regarding claim status. Applicant acknowledges that submission of false information may result in denial of the rebate and recovery of funds.

Applicant Initials:

Miscellaneous

No failure or delay by Provider in exercising any right under this Agreement shall operate as a waiver of such right. If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

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