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2. Water Conservation Program - High Efficiency Toilet Rebate Program

4. APPLICANT INFORMATION

6. Name*
8. Mailing Address*
10. City*
11. State*
12. Zip Code*
14. Retrofit Address (if different from above)
16. Phone Number*
17. Email Address*
19. Are you the property owner or tenant?*

    1. Property Owner
    2. Tenant
20. Account Number (Utilities)*

24. FIXTURE INFORMATION

26. Brand Name*
27. Model Name*
29. Purchase Price*
30. Purchase Date*
32. Number of Toilets in Building*
33. Number of Toilets Being Retrofitted*
34. Installation Date (if applicable)*

36. For information on Water Sense products, visit: www.epa.gov/watersense

40. REQUIRED ATTACHMENTS

42. Please include the following with your application

    1. Owner's Authorization (if applicable)
44. Upload Required Attachment Here

48. APPLICANT CERTIFICATION

50. Acknowledgements

    1. I certify that I am the owner of record or an authorized representative acting on their behalf, or the tenant with the property owner's consent.
    2. I acknowledge that I have read, understand, and agree to the Turf Replacement Program Terms and Conditions (hereinafter referred to as the "Conditions").
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52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field