$25 programmable thermostat rebate form
$100 ENERGY STAR® certified smart thermostat rebate form
INSTRUCTIONS
1. Purchase a new smart or programmable thermostat
between January 1, 2021 and December 31, 2021.
2. Submit your rebate information online at MassSave.com/Savings or
mail the following to the address at the right before January 31, 2022:
• This completed rebate form
• A copy of the first page of your most recent electric bill
• A copy of the receipt showing the qualifying model, manufacturer,
purchase date, purchase price and store name
DO NOT mail with your utility bill.
* Required Fields
Note: To receive your rebate faster, submit online
at MassSave.com/Savings
MAIL TO:
Thermostat rebate (MA) • P.O. Box 2528
Manchester, CT 06045
CUSTOMER INFORMATION (FILL CIRCLES COMPLETELY)
Heating Fuel Type(s)*: Natural Gas Oil Electric Propane
Please select your Massachusetts Natural Gas Provider*: Berkshire Gas Eversource Liberty Na
tional Grid Gas
Unitil None
Please select your Massachusetts Electric Provider*: Cape Light C
ompact Eversource Na
tional Grid Electric Unitil
Account Holder Name*:
Account Number(s) (must match installation address)*:
Installation Address*: City: State:
MA
ZIP Code:
Payee Address (If dierent than installed address): City: State: ZIP Code:
Phone Number: Email:
CUSTOMER ACCEPTANCE OF TERMS
If payee information is dierent from account holder information and the gas utility provider is National Grid, additional processing time will be needed for payee verification. I hereby request
a rebate for the listed thermostat(s). Attached are copies of all receipts or invoices. I have read and agree to the Terms and Conditions on the reverse side of this form. I certify that the listed
equipment has been installed in accordance with Program Guidelines and Terms and Conditions as described on this form.
Customer Signature: Date:
By your signature above and acceptance of an energy eciency rebate(s) you acknowledge that the data collected through the use of the smart thermostat may be shared with your electric
and/or gas distribution company.
PRODUCT INFORMATION
Rebate not to exceed purchase price. Limit four (4) rebates per gas/electric meter.
Visit MassSave
.com/Thermostats for qualified models
Measure
Description
*Date
Installed
*Manufacturer
*Model
Number
*Does your home
have a central air
cooling system?
*Installed by
Purchase
Price
*QTY
Rebate
Amount
ENERGY STAR® Certified
Smart Thermostat
Yes
No
Self
Contractor
$100 ea.
For smart thermostats only: Customers with central AC must provide serial number and MAC address to be eligible for additional oerings.
Serial Number: MAC Address:
Programmable
Thermostat
Yes
No
Self
Contractor
$25 ea.
Rebate: Rebates over $100 are paid in the form of a check. Rebates that are $100 or less are paid in the form of a Mass Save® Visa® prepaid card. The card is not redeemable for
cash or usable at any ATM. Terms and Conditions apply to the card. Your card is issued by The Bancorp Bank, Member FDIC, pursuant to a license from Visa® U.S.A. Inc. and can
be used everywhere Visa® debit cards are accepted in the U.S. Pay close attention to the expiration date printed on the front of the card. Card is valid through the last day of
the month. You will not have access to the funds after expiration. This rebate may not be combined with any other utility or energy eciency service provider oer. Please allow
6-8 weeks for application processing. For more information and to check the status of your rebate, call 800-232-0672 or visit MassSave.com/Savings
WE ARE MASS SAVE
®
:
FOR ADDITIONAL INFORMATION, VISIT MASSSAVE.COM/THERMOSTATS OR CALL 800-232-0672.
01.21
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