Toilet Retrofit Rebate Application

2. Rebate Information
   The Toilet Retrofit rebate encourages removal of toilets using 1.6 gallons per flush (GPF) or higher and replacement with a high efficiency, water saving toilet using 0.8 gallons per flush or less. <br /> <br /> 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 $125 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.

   The Toilet Retrofit rebate encourages removal of toilets using 1.6 gallons per flush (GPF) or higher and replacement with a 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 $125 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.

4. 1. Account Information

6. Water Account Name*

7. Water Account Number

9. Date Attended Water Wiser Workshop

   Qualified applicants are required to attend a Water Wiser Workshop.

10. Photo Identification

    Please attach a copy of your photo identification. Refer to the Affidavit of Lawful Presence for acceptable forms of identification.

14. 2. Contact information

16. Contact Person*

17. Last Name*

19. Address*

21. City*

22. State*

23. Zip Code*

25. Phone Number

26. Best Time to Call

28. Email Address

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

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

34. Manufacturer / Make*

35. Model Number*

36. Gallons Per Flush

38. 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.

    The toilet must be a new, ultra-high efficiency toilet that uses 0.8 gallons per flush or less. Actual water savings may vary.

40. Manufacturer / Make*

41. Model Number*

42. Date Purchased*

44. Quantity

45. Purchase Price

46. Gallons per Flush

47. Attach Copy of Receipt

51. 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
53. Submittal Information
    Submittal of the online application is not considered complete until the AFFIDAVIT OF LAWFUL PRESENCE is signed and returned by the applicant. Once you choose "submit" you will receive a confirmation and affidavit. Please print the affidavit and return to the Program Administrator. Your rebate cannot be processed without this signed affidavit. Complete, rebate applications will be processed in the order of receipt. Rebate checks are issued within three to six weeks after receipt of a completed application.

    Submittal of the online application is not considered complete until the AFFIDAVIT OF LAWFUL PRESENCE is signed and returned by the applicant. Once you choose "submit" you will receive a confirmation and affidavit. Please print the affidavit and return to the Program Administrator. Your rebate cannot be processed without this signed affidavit. Complete, rebate applications will be processed in the order of receipt. Rebate checks are issued within three to six weeks after receipt of a completed application.

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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