2021 Toilet Rebate Application Fill In

2021 Toilet Rebate Application greeleygov.com/rebates [email protected] 970-336-4134 Customer Name: ______________________________________ Phone Number: ______________________ Installation Address: ____________________________________ Alternate Phone: _____________________ Mailing Address: _______________________________________ City, St, Zip: _________________________ (only if different from installation address) E-mail:_________________________________ City of Greeley Water Acct #__________________________ Customer Type Homeowner Renter Landlord Other __________________ The Water Conservation Program will only rebate .8 gpf or lower toilets & Dual Flush that 1.1 gpf or less. New toilet(s) Only two toilets per household will be rebated. Old Toilet(s) Must1 use. Gals more per than flush 3 _______gal/flush. # of toilets_____ 1. Gals per flush2. Gals _______ per Date purchased__________ Where purchased _____________ Manufacturer_________________ Model__________________ 2. Gals per flush _______ Affidavit of Lawful Presence Please see full instructions on back. This section must be completed and must accompany an WaterSense® is voluntary, rather than a eligible ID. (If mailed must also be notarized) regulatory program. The USEPA develops specifications for water-efficient products I, (Please print name) _________________________________ through a public process. If a manufacturer makes a product that meets those specifications, the Swear or affirm under penalty of perjury under the laws of the product is eligible for third-party testing to ensure state of Colorado that: the stated efficiency and performance criteria have been met. If the product passes the test, the I am a United states Citizen, or manufacturer is rewarded with the right to put the WaterSense® label on that product. I am a permanent resident of the United States, or I am lawfully present in the United States Notary Stamp and Signature (Only needed if mailed) I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. Signature:_____________________________ Date:_________ __________________________________________________ Signature & Date City use only: Date received: __________________2021 Received: by mail in person by email ________# of toilets Approved Denied Voucher Amount of Rebate $ _________________ Received by: ____________ Approved by: _____________ Entered by: ___________ Vendor Number: _____________ 2021 TOILET REBATE INFORMATION AND PROGRAM RULES Important: Conservation program only rebates .8 gpf flush toilets @ $50. An additional $25 will be given for recycling your toilet and is only in conjunction with the rebate. High efficiency toilet rebate rules: Toilet(s) must be purchased between January 1, 2021, and December 31, 2021. Rebate applications MUST be submitted within 90 days of purchase. All toilets purchased between October 1, 2021, and December 31, 2021, must be submitted before January 14, 2022. Rebates are subject to available funds. (Please call to confirm if you are doing an multifamily project) The purchased toilet must be for use at an address that receives a City of Greeley water bill. Residents of other cities and/or customers of other water providers are not eligible. A Greeley water account number is required. Only Greeley water customers in good standing (account with a zero balance) may apply. If renting, you must have a letter signed by owner authorizing you to install a new toilet. Rebate is limited to two toilets per residence. New toilets must replace 3.0 gallon per flush toilets (gpf) or 1994 and older. Conservation program only rebates 0.8 gpf toilets @ $50. Dual flush toilets must average 1.1 gpf or less. The City reserves the right to inspect the installation of any appliance for which a rebate is provided. Rebates can be filed by the property owners or renters. Contractors or others working for a property they do not own cannot apply for the rebate. The homeowner is responsible for installation. Information to Apply: The city can no longer accept the toilets for recycling at the GROW recycle center in Greeley, please see two alternate places below where you can recycle your toilet in Fort Collins. All non-porcelain parts must be removed to drop off the toilet and receive the voucher i.e. seat, plastic, tank parts and metal screws, etc. Doing so will qualify you for an additional $25 when done only in conjunction with the rebate. Timberline Recycling Center City Streets Crushing Facility 1903 S Timberline Rd. (Fort Collins) 1380 Hoffman Mill Rd. (Fort Collins) 970-416-2032 970-482-1249 Hours: Tues.-Sat. 8 a.m. to 6 p.m. Hours: Mon.-Fri., 7 a.m.-5 p.m. (Apr. - Oct.) Tues.-Sat. 8 a.m. to 4:30 p.m. (Nov. - Mar.) Mon.-Fri., 7:30 a.m.-4 p.m. (Nov. - Mar.) Facilities are subject to closure during periods of inclement weather. Call ahead to confirm business hours. For more information https://www.fcgov.com/recycling/dropoff.php Applications are accepted by email or by mail. Not in-person during COVID lock down while offices are closed to the public. If you file by mail you will need to have the application notarized. Identification will also be required. A Colorado driver’s license is the preferred form of ID. We will also accept U.S. military card or passport. Please inquire about other forms of ID. Including out-of-state driver’s licenses. Mail completed form and receipt of purchase to the Water Conservation Office: 1001 11th Avenue, 2nd floor, Greeley, CO 80631. OR email to [email protected] Application check list Mail in or email: Applying in person: Not available during COVID-lock down Application completed with affidavit signed Application completed with affidavit signed Original or readable copy of receipt (dated within last 90 days) Original receipt (dated within last 90 days) Copy of driver’s license ID or Colorado driver’s license Recycling voucher if applicable Recycling voucher if applicable .

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