CITY OF PALMETTO, FL Application Number Indoor Water Conservation Program Rebate Application

Instructions: Participation in the City of Palmetto Indoor Water Conservation Program is easy. 1.) Upon receipt of this application you will have 30 days for the installation of your new toilet(s) and to return this completed application to the address below. 2.) When returning this application attach copies of your purchase receipt(s) and a copy of your water bill unless your park or condo association pays the water bill; then provide the name of the association that pays the water bill directly to the City of Palmetto Utilities. 3.) After your installation verification has been completed and approved, you will receive your rebate check in approximately 4 to 6 weeks. Rebates are available for single family, multi-family, and commercial building owners or authorized agents. 4.) This program applies to Wholesale and Retail Water Customers of the City of Palmetto. High Efficiency (HE) toilets must be ANSI certified to use 1.28 gallons or less per flush for residential accounts and Ultra Low Flow toilet (ULFT)(1.6 gallons per flush) for commercial accounts that replaces a high-volume toilet installed prior to 1995. Residents whose primary water bills are paid directly to the City of Bradenton, Town of Longboat Key, Manatee County, or Sarasota County are NOT eligible for this rebate. Questions? Please call (941) 417-2890.

Palmetto City Hall PLEASE MAIL YOUR APPLICATION TO: 516 8th Ave W, Palmetto, FL 34221

BUILDING AND ACCOUNT DATA (INSTALLATION ADDRESS) Account Name Building Type Owner Occupied: Rental/Leased Unit: ☐ Single Family ☐ Single Family Street Address ☐ Condo/Townhouse ☐ Condo/Townhouse City, State, Zip Code ☐ Mobile Home ☐ Mobile Home ☐ Duplex/Triplex ☐ Multi-Family (2+ units) All correspondence will be sent to the OWNER or AUTHORIZED ☐ Commercial AGENT at this address. Water Account Number Name of Association paying Does this account serve more than one unit? water bill (if this is a master ☐ Yes If yes, how many? metered account) ☐ No

REBATE CHECK PAYABLE INFORMATION VERIFICATION APPOINTMENT CONTACT INFO If you wish to assign your rebate check to someone other Person to Contact than the OWNER or AUTHORIZED AGENT please complete this section: Name Day Phone Evening Phone

Mailing Address Best Time to Call

City, State, Zip REBATE CHECK INFORMATION Applicant Name

Phone Fax v. 9/11/2019 2:58 PM Page 1 of 2 APPLICATION IS INCOMPLETE WITHOUT THE 1.28 GALLON TOILETS INSTALLED FOLLOWING INFORMATION: NO. OF TOILETS QUANTITY BRAND MODEL IN HOUSEHOLD Number of dwelling units to be inspected: ______

Total toilets installed: ______

CERTIFICATION AND TERMS AND CONDITIONS I hereby certify that I am the Building Owner and/or Authorized Agent for the above listed property where water service is provided. I have read and agree with the terms and conditions of the City of Palmetto Indoor Water Conservation Rebate Program policy and procedures. I have abided by the Project and Procedures and have read the Consumer Awareness Form that accompanies this application. 1.) Not all HET/ULF toilets perform alike. Choose yours carefully. 2.) The City of Palmetto does not guarantee toilet performance or workmanship. 3.) The City of Palmetto reserves the right to withhold a rebate for failure to comply with project requirements. 4.) ALL toilets for which a rebate is applied must be verified by an on-site confirmation to ensure a HE/ULF toilet replaced a 3.5 gallon or higher toilet. DO NOT DISPOSE OF YOUR OLD TOILET PRIOR TO VERIFICATION. 5.) Any toilet not self-installed by a single-family homeowner, MUST be installed by a Licensed Plumber. 6.) A Licensed Plumber MUST be used when replacing any toilet in a leased or rented single family unit, multi-family or commercial property. A receipt showing the material and installation costs, and the plumbers name, address, phone number and license number must be provided in order to receive a rebate. 7.) Plumbers must be licensed in the State of Florida. 8.) Rebates are available on a first come, first serve basis.

SIGNATURE DATE NAME (Please Print) This program is cooperatively funded by the City of Palmetto and the Board of the Southwest Florida Water Management District.

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