WaterSense Toilet Rebate Program

WaterSense Toilet Rebate Program

A part of Indoor Water Conservation Programs brought to you by the participating utilities of Polk County and Polk Regional Water Cooperative
Program Qualifications:

Active water utility customer of Polk County UtilitiesOld toilets is 3.5 gallons/flush or greater if home was built before 1994, and no new toilets have been installed since 1995, then toilets are considered to be 3.5gallons/flush or greater and will qualify)Old toilet(s) will NOT be re-installed at any location, and will be rendered unusable or disposed ofNew toilet(s) is 1.28 gallons/flush and is a WaterSense® labeled toilet(s)
Steps to Apply
1. Complete this form and submit it to your utility using the contact information above. If you qualify for the program, a reservation number will be issued to you, allowing 30 days for the installation of new toilet(s) and submission of required documents.
2. Keep your original toilets until contacted by the utility for inspection usually within 2 weeks
3. After installation, submit the following required documents by mail, email or fax to the contact above. Be sure to include your reservation number
4. Pictures of the old toilet(s) in place, with special focus on manufacturer stamps inside back of tank.
5. Pictures of the new toilet(s) in place
6. Your purchase receipt
7. Plumber information (name, address, phone number, and license number), if applicable
You will be contacted to set up an inspection appointment to verify the new and old toilets

You will receive your rebate check of up to $100 per toilet (maximum of 2 toilets per family), not to exceed the total price of toilet(s), required components and installation, in approximately 4 weeks
Applicant Information:
Utility
Billing Account #
Last Name*
First Name*
M.I
Street Address*
Unit #
City*
Zip Code*
U.S. Phone
Email*
example@example.com
Mailing Address (if different from above)
Relationship to property*
Owner, Tenant, etc.
Building Information:

Please enter the number of toilets to be replaced
Single Family Residence
(Up to 2)
Commercial or Multi-Family Residence
(# of residential units)
Old toilet(s) gallons per flush*

3.5 gpf5 gpf7 gpfunknown
Please specify year built*
The home must have been built before 1995. Information can be found on Polk County Property Appraiser Website www.Polkpa.org Property search, view PRC file
Have new toilets been installed since 1994?*

YesNoUnknown
Pictures of the old toilet(s) in place, with special focus on manufacturer stamps inside back of tank.

Cancelof
Pictures of the new toilet(s) in place

Cancelof
Agreement of Term and Conditions
The utility may deny any application that does not meet program requirements. The undersigned expressly agrees that the utility may inspect all items submitted for the WaterSense® Toilet Replacement Program. The undersigned further agrees to hold harmless the utility and/or Polk Regional Water Cooperative against all loss, damage, expense, and liability resulting from the loss, destruction of damage to property arising out of or in any way connected with the installation of the WaterSense® Toilet Replacement Program. The utility reserves the right to alter this program at any time. Funding for the rebate program is limited to available resources. Rebates are processed on a first come, first served basis. For further questions, please call your utility.

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

Clear
Date*

MonthDayYear
Date
For Official Use Only
Reservation #
Application

ApprovedDenied
Reviewed by
Reason for Denial
Documentation Confirmation

Old Toilet PhotoNew Toilet PhotoReceipts
Follow-up Inspection

YesNo
Date of inspection

MonthDayYear
Date
Follow-up Inspection

ApprovedDenied
Inspector
Total cost
Customer cost
Utility cost
District cost
Date to Accounting

MonthDayYear
Date
Amount of Rebate
Date Rebate Check sent

MonthDayYear
Date
Check Sent By
Check #
Should be Empty:

WaterSense Toilet Rebate Program

Applicant Information:

Building Information:

Agreement of Term and Conditions

For Official Use Only