City of Peoria
Sustainability & Water Conservation
Residential High Efficiency Toilet Rebate
Limit three per water account
Water Billing Account Number (XXXXX-X)
*
Name on Utility Account
*
First Name
Last Name
Address
*
Street Address
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Brand of High Efficiency Toilet #1
*
Model of High Efficiency Toilet #1
*
Brand of High Efficiency Toilet #2 (skip if not applicable)
Model of High Efficiency Toilet #2 (skip if not applicable)
Brand of High Efficiency Toilet #3 (skip if not applicable)
Model of High Efficiency Toilet #3 (skip if not applicable)
Date of Toilet Installation
*
-
Month
-
Day
Year
Date
High Efficiency Toilet installed by:
*
Self
Contractor
Have you previously participated in a City of Peoria Sustainability & Water Conservation Program?
*
Yes
No
How would you describe your current level of familiarity with water conservation practices?
*
Extremely Familiar
Moderately Familiar
Somewhat Familiar
Slightly Familiar
Not At All Familiar
How did you first hear about this program?
*
Please Select
Bill Insert (PeoriaNOW)
City Building (Library, etc.)
City Employee
City Event
City Mail (Sustain & Gain, etc.)
City Website
New Customer Email
Email/Newsletter
Family/Friends/Neighbor
HOA/Community Org
Internet Search
Landscaper/Contractor
News Outlet
Peoria School
Social Media
Store/Business
Choose the option that fits best.
SUBMIT REQUIRED DOCUMENTATION: (#1) Picture of an itemized receipt showing the subtotal cost of the toilet(s) before tax & total amount paid, the date purchased, and the business you purchased the item from. (#2) Pictures of the installed toilet(s), text underneath the toilet tank(s), and any supportive pictures displaying the toilet(s) brand, model, and gallons per flush.
*
Browse Files
Drag and drop files here
Choose a file
Applied discounts towards the total payment will be subtracted from the subtotal cost. Taxes and installation costs do not qualify for a rebate. The amount of a rebate cannot exceed the amount paid.
Cancel
of
I certify that the installed High Efficiency Toilet(s) are WaterSense certified, 1.28 gallons per flush or less, and the information provided above is true and to the best of my knowledge.
*
PLEDGE TO SAVE WATER
Submit
Should be Empty: