ENERGY STAR® Clothes Washer & Dryer Incentive

Note: Incentive must be redeemed within 6 months of purchase date. Your purchase receipt must accompany this form.

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Account Number

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Email(Required)

Location of Install(Required)

Same as previous

Street Address Address Line 2 City State ZIP Code

Style(Required)

Front Loader

Top Loader

Brand Name(Required)

Model Number(Required)

Purchased At

Brand Name(Required)

Model Number(Required)

Purchased At

Purchase Receipt(Required)

Your purchase receipt must accompany this form.

Max. file size: 50 MB.

Member Signature (Full Name)(Required)

This form is also available to download, print, and return: Clothes Washer & Dry Incentive Form (PDF)