Fillable Toilet (HET) Rebate Residential High-Efficiency Application (CITY OF FOREST GROVE)

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Toilet (HET) Rebate Residential High-Efficiency Application (CITY OF FOREST GROVE)

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The Toilet (HET) Rebate Residential High-Efficiency Application (CITY OF FOREST GROVE) form is 1 page long and contains:

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  • 2 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

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2020-01
Residential High-Efficiency
Toilet (HET) Rebate
Application
City of Forest Grove
APPLICANT INFORMATION
Last name:
First name:
Installation address:
Mailing address (if different):
Phone #:
E-mail:
Utility billing account #:
Homeowner Tenant (complete homeowner information)
HOMEOWNER INFORMATION
(complete only if different than applicant information)
Last name:
First name:
Address:
Phone #:
Homeowner signature: ________________________________________
Date: ___________________________
TOILET INFORMATION
Toilet 1
Manufacturer:
Model name:
Model #:
Date purchased:
gpf:
Price:
Toilet 2
Manufacturer:
Model name:
Model #:
Date purchased:
gpf:
Price:
I certify the information I have provided is true and correct, and I have purchased the products to replace non-efficient
products at the location indicated. I grant permission to the City of Forest Grove, with notification, to enter upon the
property to inspect the installation of rebate products to assure program requirements are met. I understand rebates are
distributed on a first-come first-served basis until all funds are distributed, and may be discontinued at any time without
notice. I have read and understand the eligibility requirements and terms of the Forest Grove Residential HET Rebate
program.
Applicant signature: _________________________________________
Date: ___________________________
FOR OFFICIAL USE ONLY
Date received:
Approved by:
Attach copy of Payment Request
Rebate amount:
Vendor #:
Expected check date:
CITY OF FOREST GROVE ∙ ENGINEERING | PO BOX 326 ∙ FOREST GROVE, OR 97116 | 503.992.3228 | www.forestgrove-or.gov
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2020-01
Residential High-Efficiency Toilet (HET) Rebate Program
ELIGIBILITY REQUIREMENTS:
• Applicants must live in a single-family residence within the City of Forest Grove service area.
• Applicants must have a current City of Forest Grove utility billing account in good standing; utility
billing accounts in “past due” status will not be eligible for rebates.
• Applicants must include a copy of proof-of-purchase receipt from retailer or plumbing company that
specifies the purchase date, purchase price, manufacturer, and model number.
• Applications must be received within 60 days of the purchase date.
• Prior to approval, an on-site inspection may be required by a City of Forest Grove Inspector.
• Installed toilet must be EPA WaterSense certified
(1.28 gallons per flush or less) AND replace non-
efficient toilet.
TERMS OF REBATE:
• $75 HET rebate; limit 2 HET rebates per household.
• Eligibility is based on a first-come, first-served basis until all funds are distributed; program may be
discontinued at any time without notice.
• The total rebate per item will not exceed the receipt amount.
• Rebates will be mailed in the form of a check to the address specified on the rebate application; rebates
will not be credited to the utility billing account.
• As a condition of rebate program, it shall be tenant/property owner’s responsibility to properly
dispose of the non-compliant fixture.
CHECKLIST:
Toilet was installed in a single-family residence
Applicant is listed on utility account
Proof-of-purchase attached and includes the HET manufacturer, make and model, purchase date
Toilet is EPA WaterSense certified HET
Rebate has not previously been issued at this address
Utility Billing account is not past due
(Pay your bill online at https://www.municipalonlinepayments.com/forestgroveor/utilities
)
Submit completed rebate application and proof of purchase within 60 days of purchase
In person:
City of Forest Grove
Engineering Office
1928 Council St.
Forest Grove, OR 97116
By mail:
City of Forest Grove
Attn: Engineering Office
PO Box 326
Forest Grove, OR 97116
By email:
mcrowell@forestgrove-or.gov
QUESTIONS? Contact Marcey Crowell at (503) 992-3228 or mcrowell@forestgrove-or.gov
Find more ways to conserve water by visiting: https://www.regionalh2o.org/
Take advantage of these FREE water saving devices available at the Engineering office (while supplies last):
• Faucet aerators
• Outdoor watering gauges
• High efficiency hose nozzles
• High efficiency shower heads
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Toilet (HET) Rebate Residential High-Efficiency Application (CITY OF FOREST GROVE)

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Completed 13 February 2021

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