Residential High Efficiency Toilet - Rebate Program Application 7/1/19 - 6/30/20

2. Name*

3. Email Address

   Providing an Email address will speed up the response time to your application.

5. Address*

7. City*

8. State*

9. Zip Code*

11. Phone Number*

13. Verify Phone Number*

17. Are you the Property Owner?*

    1. Yes
    2. No

18. Year Home was Built*

19. Have you previously applied for this rebate?*

    1. Yes
    2. No

21. NOTE: Tenants: Participation requires written approval from property owner/property manager.

    Attach to application

22. Please indicate the date of the last rebate.
    Please indicate the date of the last rebate.

26. Current Toilet(s)
    Please provide the following if legible. (Manufacturer date/model is usually found stamped under the inside of the toilet lid or back of tank)

    Please provide the following if legible. (Manufacturer date/model is usually found stamped under the inside of the toilet lid or back of tank)

28. Year Manufactured

29. Manufacturer and Model Name

30. Gallons per flush

34. New Toilet(s)
    How many gallons per flush (GPF) does the NEW toilet(s) purchased use? (Ask retailer if unsure)

    How many gallons per flush (GPF) does the NEW toilet(s) purchased use? (Ask retailer if unsure)

36. Number of Rebates Requested*

    (Separate application required for each address)

38. Manufacturer*

39. Gallons Per Flush (GPF)*

41. Manufacturer

42. Gallons Per Flush (GPF)

44. Manufacturer

45. Gallons Per Flush (GPF)

47. Receipt(s)*

49. Where did you hear about the rebate?*

53. Inspection
    <ul><li>When the completed application is approved, an appointment may be scheduled for a brief visual inspection by the City.</li>

    • When the completed application is approved, an appointment may be scheduled for a brief visual inspection by the City.

55. Rebate Information
    <ul><li>The rebate value may not exceed the actual cost of the toilet(s).</li><li>An original itemized dated sales receipt is required to qualify for the rebate.</li><li>Limit of up to 3 toilets per account per fiscal year (July 1, 2019 - June 30, 2020).</li><li>Rebate application must be received within 60 days of sales receipt.</li><li>Compliance with the attached guideline is required.</li>

    • The rebate value may not exceed the actual cost of the toilet(s).
    • An original itemized dated sales receipt is required to qualify for the rebate.
    • Limit of up to 3 toilets per account per fiscal year (July 1, 2019 - June 30, 2020).
    • Rebate application must be received within 60 days of sales receipt.
    • Compliance with the attached guideline is required.

57. Terms and Conditions
    The City of Modesto may deny any application that does not meet program requirements. The undersigned expressly agrees that the City may inspect all items submitted for the High Efficiency Toilet Rebate Program. The City does not guarantee the performance of any toilet; does not warrant any toilet or installation to be free of defects, the quality of the workmanship, or the suitability of the premises or the toilet for installation. The undersigned further agrees to hold harmless the City of Modesto against all loss, damage, expense, and liability resulting from the loss, destruction or damage to property arising out of or in any way connected with installation of a toilet. The City reserves the right to alter this program at any time. Funding for this rebate program is limited to available resources. Rebates are processed on a first come, first served basis. For further information, please call (209) 342-2246.

    The City of Modesto may deny any application that does not meet program requirements. The undersigned expressly agrees that the City may inspect all items submitted for the High Efficiency Toilet Rebate Program. The City does not guarantee the performance of any toilet; does not warrant any toilet or installation to be free of defects, the quality of the workmanship, or the suitability of the premises or the toilet for installation. The undersigned further agrees to hold harmless the City of Modesto against all loss, damage, expense, and liability resulting from the loss, destruction or damage to property arising out of or in any way connected with installation of a toilet. The City reserves the right to alter this program at any time. Funding for this rebate program is limited to available resources. Rebates are processed on a first come, first served basis. For further information, please call (209) 342-2246.

59. Electronic Signature*

    1. I have read, understand, and agree to the terms and conditions of this rebate program.

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60. Submit Submit and Print

* indicates a required field