2. 1. Account Information
4. Rebate Information

   The Toilet Retrofit rebate encourages removal of toilets using 1.6 gallons per flush (GPF) or higher and replacement with an ultra-high efficiency, water saving toilet using 0.8 gallons per flush or less.

   
   

   Applications are processed in the order received and rebates are distributed on a first-come, first-served basis. Funding is limited. Rebate will reimburse participant up to $150 of the purchase price of a new toilet (excluding installation costs, taxes and shipping/handling) up to a maximum of four (4) toilets. Residential and non-residential customers are eligible for this rebate. All expenses are out-of-pocket to the applicant. Toilets must be new and meet qualifying criteria. Toilet must be purchased and installed at the water account address, in the Town of Castle Rock Water service area, during the current rebate year. The "old" toilet must be delivered to Castle Rock Water, by appointment, for recycling.

6. Water Account Name*
7. Water Account Number
9. Date Attended Water Wiser Workshop
   Qualified applicants are required to attend a Water Wiser Workshop.
11. Preferred rebate method:*

    1. Check
    2. Castle Rock Water bill credit
15. 2. Contact information
17. Contact Person*
18. Last Name*
20. Address*
22. City*
23. State*
24. Zip Code*
26. Phone Number
27. Best Time to Call
29. Email Address
33. 3. "Old" Toilet Information

    To be eligible for a rebate, you are required to bring in the less water efficient toilet at a prescribed scheduled time. Old toilets must be prepared and cannot be dropped off without an appointment.

35. Manufacturer / Make*
36. Model Number*
37. Gallons Per Flush
39. 4. "New" Toilet Information
    The toilet must be a new, ultra-high efficiency toilet that uses 0.8 gallons per flush or less. Actual water savings may vary.
41. Manufacturer / Make*
42. Model Number*
43. Date Purchased*
45. Quantity
46. Purchase Price
47. Gallons per Flush
49. Attach Copy of Receipt*
53. Photo Permission

    Upon approval of this application, the Town of Castle Rock has the right and license to use my image, likeness, and comments in Castle Rock materials for internal and external audiences. These materials include, but are not limited to, advertisements, brochures, new releas-es, magazines, newspapers, newsletters, videos, and presentations.

    1. I agree
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field