Page 1 of 3
SNS-YERP-CS-V.28.01.19
For Office Use Only
File # ______________________
Consumer Application for Your Energy Rebate
A. Name
(first, middle initial, last)
B. Contact Information
Home Phone #
Email Address:
Alternate #
C. Authorized Representative (Complete only if you wish to appoint a representative)
Name
Phone #
I hereby give my authorization for my authorized representative to speak to Service Nova Scotia with regards
to my application.
D. Address Information
Civic Address of Property Related to this Claim
Mailing Address (if different than civic address)
Street No. And Name
Street No. And Name
(Unit/Suite/Apt #)
(Unit/Suite/Apt #/
PO Box or RR #)
City, Town or Village
City, Town or Village
Province
NS
Postal Code
-
Province
NS
Postal Code
-
RESET
Page 2 of 3
SNS-YERP-CS-V.28.01.19
Section 2 Invoice/Rebate Details and Work (Please attach invoice and/or receipts)
A.
Please indicate below the time period from the date on your first receipt to the date of your last receipt.
Period from (earliest purchase date)
Period to (last purchase date)
d
d
m
m
y
y
d
d
m
m
y
y
B.
Please complete the following table for each energy type being claimed.
The energy type must be one of the following: Oil (furnace or stove), Propane, Kerosene, Wood, Wood Pellets, Coal,
Natural Gas and Electricity.
Energy Type (See above)
Receipt # / Purchase Date
Supplier
Total Amount before HST
Eg. Oil
39051 December 1, 2017
Mr. Oil
500.00
Subtotal
X .10
Rebate Amount
Page 3 of 3
SNS-YERP-CS-V.28.01.19
Section 3 - Application Declaration
Section 3 - Application Declaration
I hereby certify that:
The information contained in this application is true, complete and correct in every respect.
I am the person described on this application and I am entitled to the amount claimed.
The energy purchases covered by this claim were for residential use only.
It is acknowledged that property tax information may be used in an audit of my claim.
This amount was not previously claimed.
All invoices/receipts are attached.
Date l l l l l l l
Applicant’s Name (Please print) Applicant’s Signature d d m m y y
Note: It is a serious offence to make a false application for this rebate and action to do so may result in criminal charges and/or a fine.
Return original copy of rebate application to:
By Mail:
Service Nova Scotia
P.O. Box 2632
Halifax, Nova Scotia
B3J 3P7
By Delivery:
Service Nova Scotia
Maritime Centre, 9th Floor North
1505 Barrington Street
Halifax, Nova Scotia
For more information
Website: novascotia.ca/rebate-equal-provincial-portion-hst-paid-home-energy-products-your-
residential-property
Call: (902) 424-5200 (metro) or (toll free in Nova Scotia) 1-800-670-4357
Email: yourenergyrebate@novascotia.ca