Residential Air Conditioning Rebate Application Form

Use the form below to fill in your account information and information about the rebate program you are applying for. Once you've completed the form, PRINT THE FORM, SIGN IT, and submit it with all applicable receipt copies within 90 days of purchase to:

Failure to provide complete customer information, signature(s), model numbers, or receipt copies may result in processing delays. Please allow 4-6 weeks for processing.

Name on Utility Account Account #

Zip CodeInstallation Address Phone

Mailing Address (If different)

Customer Information

Make Condenser Evaporator Tonnage SEER/EERDate Bought

I certify that I am the owner(s) or tenant(s) of the real property where the improvements have been installed and that I have not previously received, or applied for, other utility financing or incentives for the improvements on this application. I also certify that the foregoing information is true and correct. I understand and agree that the choice of improvements, the selection of contractors, the purchase of items and acceptance of materials used and work performed and the payments thereof is my responsibility. I understand that I will be fully liable for any damage to person or property that may be caused by the installation and/or operation of the equipment involved. I understand that Riverside Public Utilities does not endorse, recommend or make any representations as to specific brands, products, contractors or dealers nor does it guarantee material or workmanship. I further agree to indemnify and hold harmless the City of Riverside, its officers, employees, and agents from any damages related to the use or installation of the air conditioner/heat pump.

Signature of Applicant __________________________________ Date __________

Signature of Owner _____________________________________ Date _________ (If Applicant is renter or tenant)

FOR OFFICE USE ONLY

JL Key 6020109080 Object 45602500 Rebate Amount

Certification of Delivery Approved for Payment Approved for Payment

Signature Date Department Head Date Finance Department Date

RPU Inspector Information: Date Inspected ______________ By __________________________ Notes __________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________

Air Conditioning System Information Central AC Heat Pump Replacement New Unit

Contractor Name Contractor License #

HVAC Tune Up (Enter Tonnage)Programmable Thermostat (WiFi-enabled)

E-mail

Riverside Public Utilities - Programs & Services - 3750 University Ave. - 3rd Floor - Riverside, CA 92501Or e-mail RPURebates@riversideca.gov

RPU Electric Customers Only

(Minimum15 SEER)