Attach original toilet purchase receipt(s) and photo(s) of installed toilet(s) For more information call 520-439-2178
If mailed, write to above address - attention Community Development
________________________ _______________________
Last Name First Name
________________________________________ ________________
Street Address, Apt. # City and State Zip code
______________________
Phone
____________________________
Email
________________ _______________________
Date Number of Toilets Replaced
__________
Zip Code
_________________________________________
_________________________________________
Street Address, Apt. #
_________________________________________
___________________________ ________________________
Signature Date
Yes
No
_________
_________
Old (Replaced)
Customer Name
(Person who is to receive rebate)
Mailing Address
Contact Info
Toilet gallons per flush
Purchase date of 1.28 gallon
or
less WaterSense toilet
Store where purchased
Toilet(s) Installation Address
House built before 2013?
Toilet Installation Date
Property Owner
New
City of Sierra Vista Use Only
Requisition # ______________
Rec'd (OK to Pay)
__________
Date _____________________
Approved _________________
Gp/f Savings _______________
Rebate Total _______________
Processed By _______________
(If known)
Note: All rebates provided will be on a first come, first served basis for
RESIDENTIAL CITY SEWER CUSTOMERS ONLY, subject to availability of funds
•The City of Sierra Vista is offering the Toilet Rebate Program as part of our ongoing water conservation efforts. By replacing existing toilets with EPA
WaterSense approved models not exceeding 1.28 gallons per flush (gpf), a rebate of $50-100 will be provided for each toilet replaced, limit two per
household.
•The gpf of toilets can often be found stamped on the toilet itself.
•Tenants/Renters who wish to participate should contact their property owner/manager. Rebates require the consent of the property owner on the
application itself. It is the responsibility of the owner to insure proper installation.
•The City recommends that the installation be performed by a licensed, qualified plumber (see back page for list); and sewer line(s) be cleaned at the
time of installation, if they have not been cleaned within the previous twelve months.
WaterSense Toilet Rebate Application
Receive up to $100 back on qualifying toilet purchase
Sierra Vista City Hall
1011 N Coronado Drive
Sierra Vista, Arizona 85635
click to sign
signature
click to edit
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