Rain Barrel Reimbursement Application
Section 1:
Applicant/Property Owner Email Address Phone
Project Address City State Zip Code
Have you submitted an application previously? Yes No
Section 2:
Reimbursement Amount: (50 percent or $75, whichever is the lesser value, limit one reimbursement per household).
Cost of Project Reimbursement Amount Requested
I have included a copy of the itemized and dated purchase receipt for rain barrel and
supplies.
Program Details:
• City Staff will need access to your property to inspect the project prior to reimbursement.
• Reimbursement will be made after the project is complete.
Section 3:
Applicant/Property Owner Signature Date
By signing this application, I agree to the conditions of this program and have provided the documents needed for reimbursement.
This Section to Be Completed By City
ALL DOCUMENTS ENCLOSED? Yes No
STAFF APPLICATION APPROVAL Yes No
AMOUNT REQUESTED: __________________________ AMOUNT APPROVED: _______________________
DIRECTOR APPROVAL
_________________________________________________ ___________________________________
Signature Date
click to sign
signature
click to edit
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