City of Folsom High Efficiency Toilet Rebate Application
Important: Please read the application materials carefully and keep a copy for your records. Please type or print clearly in ink, then mail completed application and original cash register receipt and/or plumber's invoice to the City of Folsom. Use one application per property location. Residential, commercial, industrial institutional and multi- family applicants are eligible. The number of rebates is dependent upon the availability of program funds. All information on this application form is considered confidential. Applications are processed in the order received. Funding is limited, therefore, rebates are not guaranteed.
WATER ACCOUNT NUMBER ASSESSOR'S PARCEL NUMBER
APPLICANT NAME (REBATE CHECK PAYABLE TO) SSN / FED. TAX IDENTIFICATION (ID) (if the total rebates amount to a sum exceeding $600)
COMPANY NAME (BUSINESSES ONLY) APPLICATION DATE
PHONE PHONE (EVE) BEST TIME TO CALL
MAILING ADDRESS YEAR BUILT
CITY STATE ZIP
Have you received or applied for other rebates from the City of Folsom. Yes No Please consultant a tax adviser for advice on the tax liabilities of receiving any rebates. Name and address of property where toilets will be installed:
PROPERTY / SITE NAME (IF APPLICABLE)
ADDRESS CITY ZIP
NUMBER OF TOILETS ON PROPERTY NUMBER OF TOILETS FOR REBATE
MAKE(S) AND MODEL(S) REMOVED FLUSH VOLUME QUANTITY Gallons MAKE(S) AND MODEL(S) INSTALLED FLUSH VOLUME QUANTITY Gallons
TYPE OF PROPERTY: House Apartment (No. of units______) Mobile Home
Townhouse / Condominium Business / Commercial Schools and Institutions
Are you the water bill recipient for the account number listed above? Yes No
If NO, please provide the name and phone number of the water bill recipient. WATER BILL RECIPIENT NAME PHONE NUMBER
AGREEMENT I have read and understand the program information as stated in the attached application materials. I certify that I have installed said toilet(s) at the subject property. I also understand that by signing here I agree to have an official of my water provider verify the installation of the ultra-low flush
toilet(s) at said property. I agree to hold City of Folsom, Sacramento Regional County Sanitation District, and the Regional Water Authority harmless from any and all liability or claims for damage resulting from or alleged to result from the installation of the ULFT, the inspection of the premises to verify proper installation, and any other activity related to this program.
AUTHORIZED SIGNATURE TITLE (IF APPLICANT IS A BUSINESS) DATE
Mail or email applications and copies of cash register receipts and/or contractor’s invoice’s to the address listed below. For more information, call the City of Folsom, Water Management Program at 916-461-6174 or email [email protected]. Email applications to [email protected] Mail applications to the City of Folsom, Water Conservation Program at 50 Natoma Street, Folsom, CA, 95630
FOR OFFICIAL USE ONLY APPLICATION ID (For internal use only): Application received by Date received Approved Denied Reason for denial Toilets ______Rebate amount Original receipt ______INSPECTION — Required Waived Performed by Date inspected Approved Denied Reason for denial
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Folsom, and the SRCSD reserve the right to change the terms of How to get your high efficiency toilet (HET) this program at their discretion. The RWA, the City of Folsom rebate. and the SRCSD are not responsible for receipts or paperwork 1. You must first call the City of Folsom Water Management lost in the U.S. mail. The RWA, the City of Folsom and SRCSD Program at 916-461-6174 to see if rebates are available. cannot guarantee that the installation of the HETs will result in 2. Purchase and install the new toilet(s). lower water utility costs. The number of rebates is dependent upon the availability of program funds. Applications will be 3. The toilets you replace must be processed, when all required information is provided by the a. 2 gallons per flush or greater applicant; on a first-come, first-served basis. b. or a non-performing Ultra Low Flow Toilet Customer Survey (ULFT) 1.6 gallon per flush This rebate program is partially funded through a grant from the 4. You may install the toilet(s) yourself or you may hire a California Department of Water Resources. As part of that licensed contractor. 5. Return a copy of the dated receipt and/or plumber’s invoice program, we are surveying customers to understand why they with the price, model and brand of each toilet listed are making their choices regarding the replacement of toilet individually, and the completed application. Keep a copy for fixtures. In order for your rebate to be processed in a timely your records. Cost of the toilet must not exceed manner, please complete the following questions: Manufacturer’s Suggested Retail Price. 6. Submitting a signed application represents agreement to 1. Toilets are being installed in a; Home Business have the City of Folsom verify installation of the toilet, with your accompaniment. The City of Folsom will contact you to 2. How many toilets do you have in your home or schedule an inspection. Inspections are done on a random business? If a business please specify the number of basis. urinals also. ______7. Rebates are up to $175 per 1.28 gallons per flush High Efficiency Toilet. Total rebate amounts are calculated as 3. How many toilets are being replaced? ______50% of the actual sale price, not to exceed $175.00. Sale 4. For efficient toilets already installed in your home, how price must not exceed Manufacturer’s Suggested Retail Price. would you rate their performance? 8. Eligible expenses include 1.28 gallon per flush tank, bowl, Better than expected About what was expected seat, supply line, wax ring, caulking, bolts, bolt covers, and Below what was expected Don’t yet know tax. 9. The City of Folsom will issue rebate checks within eight to 5. Primary reason for replacing existing toilet. Pick one. ten weeks of receipt of your completed application materials. Bathroom remodel Toilet broken or not performing 10. The City of Folsom is required to send IRS form 1099 to the Concerned about saving water customer and the IRS when rebates total $600 or more. Other ______
Qualifications 6. If there are toilets not being replaced, please check all the reasons that apply; 1. Purchase of material must have occurred no more than 90 Toilet is already 1.6 gallons per flush days before the date of application. Existing toilet is working well 2. The number of rebates is dependent upon the availability of New toilet is too expensive program funds. 3. The location of installation must be served by the City of Other ______Folsom water service. 7. Would you consider replacing any other toilets that are not 4. Residential, commercial, industrial, institutional and multi- efficient (greater than 1.6 gallons per flush) in the next 2 family applicants are eligible. 5. Replacement of one HET with another HET is not eligible for years if additional rebates are available? yes no rebate under this program. 8. If you purchased a 1.6 gallon per flush please check all the 6. New construction is not eligible for rebate under this program. reasons that apply for not choosing a 1.28 gallon per flush or less toilet. (Not applicable for City of Folsom) Permitting Didn’t know about them Didn’t like the selection Concerned about performance (too new to the market) Building permits are not required when a residential customer Too expensive compared 1.6 gallon per flush units simply removes and installs a toilet on existing plumbing. A Other ______permit is required when a plumbing fixture will be relocated. Disclaimer 9. How did you find out about the program? Please check all that apply; The City of Folsom, the Regional Water Authority (RWA), and Utility Billing/Newsletter Newspaper/Publication the Sacramento Regional County Sanitation District (SRCSD) Radio/TV Billboard At an event reserve the right to deny an application of any participant who Friend/Neighbor does not meet all requirements as outlined. The RWA, the City of Other ______
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