Rebate Request Form

Please complete all the information in the form below to apply for a rebate. NOTE: All rebate requests must be submitted with all relevant information within 120 days of install completion date. A copy of the member's signed contract or paid receipt must accompany this application. You may attach a digital copy at the end of this form by clicking the "upload copy of receipt" button. If you need assistance submitting your receipt, please call the office at 800-537-3913 or 765-569-3133. Receipts can also be faxed to 765-569-3360 or mailed to Customer Service Dept, 119 West High Street, Rockville IN 47872.

First Name

Last Name

Account Number

Service Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Mailing Address Is Same As Service Address

Mailing Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Main Contact Number

Second Contact Number

Home Type

New Construction

Existing Home

Company Name

Contractor Name

Contractor Phone Number

Date System Was Installed

Approximate Square Footage of Home

Select System Installed

A copy of the member's paid receipt must accompany this application. Please upload a digital copy at the end of this form by clicking the 'upload copy of receipt' button. If you need assistance submitting your receipt, please call the office at 800-537-3913 or 765-569-3133. Receipts can also be faxed to 765-569-3360 or mailed to Customer Service Dept, 119 West High Street, Rockville IN 47872.

Heat Pump

Heat Pump Manufacturer

Outdoor Unit #

Indoor Unit #

Heat Pump AHRI SEER Rating

Heat Pump AHRI Reference Number

Geothermal

Geothermal Manufacturer

Geothermal Model Number

Geothermal AHRI Reference Number

Geothermal Ton

Water Heater | Dual Fuel | Heat Pump Water Heater

Manufacturer

Energy Factor

Model Number

Size (Gallons)

Heat Pump Water Heater AHRI Reference Number

Upload a Copy of Your Paid Receipt

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10 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Agreement

Incentive payment may be subject to on site verification upon discretion of Parke County REMC. It is my understanding to qualify for the rebate I am allowing the installation of a load management switch that may be subject to operation for load reduction. I also understand if I remove or request the switch be removed, I will be billed the amount of the rebate to be paid within thirty (30) days after the switch is removed.

Submission Requirements

I understand all rebate request must be submitted with all relevant information within 120 days of install completion date.

Signature

By signing below, I certify the information provided above is true and accurate.

Date of Signature

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CONTACT INFORMATION

119 W. HIGH ST., ROCKVILLE, IN 47872

(765) 569-3133 | (800) 537-3913

Contact Info