FergusonHVAC

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Mitsubishi Hurricane Relief Consumer Rebate Form

Contractors need to submit these documents: 1. Fill out claim form below. 2. Upload consumer invoice including discount taken off of job price. *Please note all rebate claims must be submitted within 30 days of installation to be eligible for reimbursement.*

Contractor Information

Company Name(Required)

Email

State Your Company Is In(Required)

Dealer Salesperson Name(Required)

Ferguson HVAC Invoice #(Required)

Homeowner Information

Homeowner Name(Required)

Homeowner Address(Required)

Street Address Address Line 2 City State ZIP Code

Install Date(Required)

Qualified Mitsubishi Systems Sold

Model Number(Required)

Serial Number(Required)

Model Number(Required)

Serial Number(Required)

Model Number

Serial Number

Model Number

Serial Number

Model Number

Serial Number

Model Number

Serial Number

Amount Claimed(Required)

Upload your copy of the invoice to the customer showing the 10% discount.(Required)

Max. file size: 16 MB.