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AED Rebate Form

AED Rebate Application

INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION: Applications must be submitted electronically and by the date and time listed in the Guidelines. Applications shall only be received from the owner or occupant of a private building located within the geographic boundaries of the City of South Jordan, required to comply with South Jordan City Ordinance 8.32, Project Cardiac React, and meeting the rebate eligibility requirements as outlined in the City of South Jordan AED Rebate Guidelines (“Guidelines”). An itemized copy of the purchase receipt must be included with the application. All sections of this application must be completed. Incomplete applications will be rejected.

Step 1 of 3

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Section 1: Identifying Information
ELIGIBILITY (TYPE OF ENTITY):*
- Licensed health care provider
- Assisted living or care center
- Child care facility with an occupant load of greater than 50 people
- Fitness center or swimming pool of one-thousand two hundred square feet or larger
- Dental office
- Municipal or private golf course
To assist with verifying eligibility, check the appropriate box to identify the type of entity which describes where the AED is located.
Entity Legal Name:*
Mailing Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Telephone*
Fax:
Federal Tax I.D. Number*
Primary Contact - Name:*
First Last
Mailing Address:*
Street Address Address Line 2 City State ZIP Code
Email:*
Telephone:
Cell Phone:
Fax:
Secondary Contact - Name:*
First Last
Mailing Address:*
Street Address Address Line 2 City State ZIP Code
Email:*
Telephone:
Cell Phone:
Fax:
Address of AED:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physical Location of Rebate Funded AED in Building/Structure:*
(If more than one AED) Physical Location(s) of Rebate Funded AED in Building/Structure:

SECTION 2: REQUEST
ITEMS PURCHASED - COST:
- AED
- AED Electrodes
- AED Batteries
- Wall-Mounted AED Cabinet
- Wall-Mounted AED Sign
Only include eligible purchases for which you are requesting reimbursement in accordance with the rebate guidelines.
Reason AED Purchased:*
- Initial Purchase
- Replace AED (eligible once every 15 years)
AED Manufacturer:*
Quantity (limited to quantity required to meet the ordinancy):*
Actual Unit Cost: (AED only - without batteries, pads, or other items)*
Eligible Rebate Amount: (Maximum rebate is $975 per unit)*
Reason AED Electrodes Purchased:*
- Initial Purchase
- Used on patient
- Expired or damaged (eligible once every five years)
AED Electrodes Manufacturer:*
Quantity of AED Electrodes:*
(limited to one per AED)
Actual AED Electrodes Unit Cost:*
Eligible Rebate Amount for Electrodes: (Maximum rebate is $140 per unit)*
Reason AED Batteries Purchased:*
- Initial Purchase
- Used on patient
- Expired or damaged (eligible once every five years)
AED Batteries Manufacturer:*
Quantity of AED Batteries:*
(limited to one per AED)
Actual AED Batteries Unit Cost:*
Eligible Rebate Amount for Batteries: (Maximum rebate is $60 per unit)*
Reason AED Cabinet Purchased:*
- Initial Purchase
- Replacement (eligible once every 20 years)
Quantity of AED Cabinets:*
Actual AED Cabinet(s) Unit Cost:*
Eligible Rebate Amount for Cabinet(s): (Maximum rebate is $175 per unit)*
Reason AED Sign Purchased:*
- Initial Purchase
- Replacement (eligible once every 20 years)
Quantity of AED Sign(s):*
Actual AED Sign(s) Unit Cost:*
Eligible Rebate Amount for Sign(s): (Maximum rebate is $45 per unit)*

SECTION 3: CERTIFICATIONS & ASSURANCES
By submitting this rebate form I certify: The rebate requested is for a Public Access AED, or other related and eligible items, located and mounted as required in South Jordan City Ordinance 8.32.*
- Yes
- No
The name, address and phone number of the AED owner, and the exact location of the AED, has been reported to Valley Emergency Communications Center (VECC) at http://www.vecc9-1-1.com.*
- Yes
- No
The AED owner understands he/she is required by law to encourage individuals who are likely to use the AED to complete a course on the administration of CPR and the use of an AED.*
- Yes
- No
The AED owner will maintain the AED in accordance with manufacturer recommendations and applicable federal, state and local laws and regulations.*
- Yes
- No
Submitted by:*
Telephone:*
Upload a copy of your receipt(s)*
Drop files here or

Max. file size: 32 MB.
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