Appliance Rebate Application

I do hereby declare that my gross household income does not exceed the maximum income for my household size as indicated in the eligible income threshold above. OR, I benefit from any of the Eligible Income-Qualified Programs listed below.

Community Action Agency Certification
Section 8 eligibility
LIHEAP certification
HUD Housing
Supplemental Social Security Income
TANF
NAHASDA

I also certify that the information presented is true and accurate. I further understand false, misleading or incomplete information may render me (the Applicant) ineligible to receive my utility’s higher income-qualified incentive. If my utility finds that any information provided in connection with this application is false, then my utility reserves the right to require reimbursement of any incentives provided to which I am not entitled. My utility reserves the right to request additional documentation or proof of income to verify income qualification and to verify benefits.