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►�Fi iCl <br />Address <br />City — <br />Phone <br />Appliance Type <br />Energy Star Rated [—]Yes ❑ No <br />Rebate Applying For (see reverse side) <br />Water Pump Size <br />State <br />Email <br />Account # <br />Model # <br />gal. Date Purchased _ <br />Rebate Amount $ <br />