Refrigerator Pick-up

Print
Press Enter to show all options, press Tab go to next option
Submit this form to complete your affidavit or request a pick-up.
Please correct the field(s) marked in red below:

1
Name:
2
Phone Number:
 *
3
Alternate Phone:
4
Address:
5
Zip:
6
Are you a Loveland Water and Power electric customer?
 *
Are you a Loveland Water and Power electric customer?
7
Is your unit in working (cooling) condition?
 *
Is your unit in working (cooling) condition?
8
Location of the unit prior to pick-up?
 *
9
Use for the unit?
 *
10
Season of use?
 *
11
Will the unit be replaced after being removed?
 *
Will the unit be replaced after being removed?
12
If yes, will your unit be replaced by a new or used unit?
If yes, will your unit be replaced by a new or used unit?
If the information is readily available:
13
Size of the appliance?
14
Manufactured Date?
15
Unit Type?
16
Brand?
17
How did you hear about the Refrigerator / Freezer Recycling Program?
The following is required by Colorado State Law as the $35 rebate is considered a public benefit.
18
I swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one):
 *
I swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one):
I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.
19
Signature:
20
Date
  1. To receive a copy of your submission, please fill out your email address below and submit.
    CAPTCHA
    Change the CAPTCHA codeSpeak the CAPTCHA code