Clothes Washer/Dishwasher
Rebate Details
Clothes Washer/
Dishwasher Rebate
Application Form
The City of Victoria is pleased to offer a rebate
program for the purchase of replacement
water-efficient appliances as a means of
promoting water conservation!
Water efficient clothes washers and
dishwashers can save you money over their
lifetime by reducing the amount of water and
energy used to run the appliance.
(Rev. March 2012)
Here’s how the rebate process works:
 Purchase an ENERGY STAR ®
qualified clothes washer and/or
dishwasher to replace an older
appliance
 Complete this application form and
attach a copy of the receipt (the
receipt must be dated for the current
year and clearly identify the model
purchase)
 Submit the application form to the
City for review
The maximum rebate is $100 per appliance, not
to exceed the cost of the appliance (including
other rebates). Limited funds are available.
Applications will be processed in the order
they are received. This program is limited to
residential City of Victoria Utility Account
customers. For information on ENERGY
STAR ® appliances, visit the ENERGY STAR
® website at:
Water Conservation for our Future
City of Victoria
Mail completed application to:
Gina Bresnahan, Permit Tech/Admin
City of Victoria
1670 Stieger Lake Lane, PO BOX 36
Victoria, Mn. 55386
www.energystar.gov
Phone: 952-443-4210
Fax: 952-443-2110
Email: [email protected]
www.ci.victoria.mn.us
City of Victoria  Clothes Washer/Dishwasher Rebate Request Form
Applicant Information
Applicant Name:
___________________________________
Mailing Address:
Address: ___________________________
City: ______________________________
State: ________ Zip: ________________
APPLICATION MUST BE COMPLETED IN FULL
Please attach a copy of the receipt for the item (s). Rebates are for the current calendar year
only. If your application is accepted, your utility account will be credited for the rebate
amount.
Clothes Washer/Dishwasher Machine Information
Make of Clothes Washer: ______________________________ Date of Purchase: ______________
Model of Clothes Washer: _____________________________ Cost of Clothes Washer: _________
Company Purchased From: __________________________________________________________
Other Rebates on the Clothes Washer? ____________________ If Yes, Rebate Amount: _________
Installation Address (if different from above):
Make of Dishwasher: __________________________________ Date of Purchase: ______________
Address: ___________________________
Model of Dishwasher: _________________________________ Cost of Dishwasher: ____________
City: ______________________________
Company Purchased From: ___________________________________________________________
State:________ Zip: ________________
Other Rebates on the Dishwasher? _____________________ If Yes, Rebate Amount: ___________
NOTE: Must be installed within a main
residence, not vacation or rental property.
Contact Information:
Home Phone: _______________________
Cell (optional): ______________________
Customer Agreement: My signature indicates
that the information provided it true, I have read
and understand the rebate program guidelines and
that I comply with the City of Victoria rebate
program requirements. Upon compliance, a rebate
will be distributed if funding is available at the time
of application. I will allow a representative of the
City of Victoria to verify the installation of my
toilet if requested.
FOR CITY OFFICE USE ONLY
Date Received: __________________
Copy of Receipt (s) Attached: _____
Total Allowable Rebate: __________
Verified by: ____________________
Signature: ________________________________
Email (optional): ____________________
Date: _________________________________
Comments: ____________________