"*" indicates required fields Select Your Water UtilityIf your water provider is not listed, they do not currently participate in our Toilet Rebate Program. Visit your water provider's website to find out if they offer a similar program. Select your Water Utility to see if they participate in our rebate program:*Bartow CountyCherokee County WSACity of AtlantaCity of College ParkCity of CummingCity of East PointCity of FairburnCity of FayettevilleCity of HamptonCity of HiramCity of McDonoughCity of PalmettoCity of WoodstockClayton County Water AuthorityCoweta County Water & Sewerage SystemCity of DallasDouglasville-Douglas County WSAFayette CountyForsyth CountyFulton CountyGwinnett CountyHenry CountyRockdale CountyDid you purchase a toilet that is 1.1gpf or less?* Yes No This program is only for toilets that are 1.1gpf or less. You are not eligible for this rebate.Rebate ApplicationCustomer Name* First Last Email Address* TelephonePlease enter the address where the new toilet(s) are installed. Please note: The address block is broken up by Street Number, Street Name, Street Designator (i.e. Street, Blvd, etc.), and Direction (if necessary).Street Number*Insert street number here.Street Name:* Street Designation:*SelectAlleyAvenueBayBendBluffBoulevardBranchBrookBrookeChaseCircleClimbCloseClubCommonCommonsCornerCornersCourtCoveCreekCrescentCrestCrossingCurveDaleDriveDownsEstatesFallFallsFieldForgeGateGroveHavenHeathHeightsHighwayHillHillsHollowHuntInletIsleJunctionKnollKnollsLandingLaneLoopManorMeadowMillN/AOaksOverlookParkParkwayPassPassagePathPlacePointPointeRideRidgeRiseRoadRowRunSquareStationStreetSummitTarnTerraceTraceTrackTrailTurnValleyViewWalkWayStreet Direction:*SelectN/AENNENWSSESWWCity*AcworthAlpharettaAtlantaAuburnAustellAvondale EstatesBall GroundBerkeley LakeBrookhavenBufordCantonCartersvilleChambleeChattahoochee HillsClarkstonCollege ParkConyersDaculaDecaturDoravilleDouglasvilleDuluthDunwoodyEast PointFairburnFayettevilleForest ParkGraysonGriffinHamptonHapevilleHolly SpringsJohns CreekJonesboroKennesawLake ParkLawrencevilleLilburnLithoniaLocust GroveLoganvilleLovejoyMariettaMcDonoughMiltonMorrowMountain ParkNelsonNorcrossPalmettoPeachtreePeachtree CornersPine LakePowder SpringsRiverdaleRoswellSandy SpringsSmyrnaSnellvilleSouth FultonStockbridgeStone MountainSugar HillSuwaneeTuckerTyroneUnion CityVilla RicaWaleskaWoodstockBraseltonBrooksRest HavenTyroneWoolseyZip Code:*Insert only the zip code here. Is your mailing address different from the installation address?* No, mailing address is same as installation address Yes, mailing address is different from installation address Please note: The address block is broken up by Street Number, Street Name, Street Designation (i.e. Street, Blvd, etc.), and Direction (if necessary).Mailing Address Street NumberInsert street number here.Mailing Address Street Name: Mailing Address Street Designation:SelectAlleyAvenueBayBendBluffBoulevardBranchBrookBrookeChaseCircleClimbCloseClubCommonCommonsCornerCornersCourtCoveCreekCrescentCrestCrossingCurveDaleDriveDownsEstatesFallFallsFieldForgeGateGroveHavenHeathHeightsHighwayHillHillsHollowHuntInletIsleJunctionKnollKnollsLandingLaneLoopManorMeadowMillN/AOaksOverlookParkParkwayPassPassagePathPlacePointPointeRideRidgeRiseRoadRowRunSquareStationStreetSummitTarnTerraceTraceTrackTrailTurnValleyViewWalkWayMailing Address Street Direction:SelectN/AENNENWSSESWWMailing Address City: Mailing Address StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JersyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingMailing Address Zip Code:Insert zip code only. Utility Billing Account #* Receipt of Purchase*Please upload the following documents: - Receipt of purchase of new toilet(s) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB. Current Water Bill*Please upload the following documents: - Recent water bill that clearly displays the account number and metered address Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB. How did you hear about the program? Friend Retailer/Plumber Water Bill Insert Website Other Household InformationRebates are limited to customers with single-family residential homes built in 1993 or earlier with toilets using 3.5 gpf or greater.Number of people in the household:Please enter a number from 1 to 10.Enter Year home was built*Only single-family residential homes built in 1993 or earlier are eligible.The purpose of our toilet rebate program is to conserve water across the region by replacing older, water-wasting toilets (using 3.5 gallons per flush or more) with new water-efficient models. Under the Energy Policy Act of 1992, all toilets sold in the United States were required to be more water efficient beginning on January 1, 1994. Since your home was built after 1993, it came equipped with more water efficient 1.6 gallon per flush toilets, and unfortunately does not qualify for the rebate program. Toilet InformationHow many toilets did you replace?*The maximum number allowable for rebate is two (2) toilets. One toilet Two toilets What is the GPF of your old toilet?*Enter the gallons per flush (gpf) of your old, replaced toilet.Select5.0 gpf or higher3.5 gpf1.6 gpf1.28 gpf1.1 gpf or lowerThe purpose of our toilet rebate program is to conserve water across the region by replacing older, water-wasting toilets (using 3.5 gallons per flush or more) with new water-efficient models. Since your original toilet used less than 1.28 gpf, it unfortunately does not qualify for the rebate program. What is the GPF of the second old toilet?*Enter the gallons per flush (gpf) of your old, replaced toilet.Select5.0 gpf or higher3.5 gpf1.6 gpf1.28 gpf1.1 gpf or lowerThe purpose of our toilet rebate program is to conserve water across the region by replacing older, water-wasting toilets (using 3.5 gallons per flush or more) with new water-efficient models. Since your original toilet used less than 1.28 gpf, it unfortunately does not qualify for the rebate program. What is the GPF of your new toilet?*Dual flush toilets will typically have two buttons and GPF would be lised as 1.0/1.6 etc. Single flush toilets just has one gpf number.SelectSingle Flush .80 gpfSingle Flush 1.10 gpfDual Flush 0.8/1.0 gpfDual Flush 0.8/1.26 gpfDual Flush 1.0/1.28 gpfWhat is the GPF of your second new toilet?Dual flush toilets will typically have two buttons and GPF would be lised as 1.0/1.6 etc. Single flush toilets just has one gpf number.SelectSingle Flush .80 gpfSingle Flush 1.10 gpfDual Flush 0.8/1.0 gpfDual Flush 0.8/1.2 gpfDual Flush 1.0/1.28 gpfModel Number of NEW Toilet #1:* Model Number of NEW Toilet #2: Toilet Program Policy:By submittal hereof, customer acknowledges that the rebate is a one-time rebate to be received only if the customer has purchased eligible toilets after September 28th, 2007 and is in good financial standing with the water utility. Customer acknowledges their home was built in 1993 or earlier with toilets using 3.5 gallons per flush or greater. Customer also acknowledges that the credit is only available for WaterSense labeled toilets ($75 for Ultra-High-Efficiency toilets using 1.1 GPF or less) with a maximum of two (2) toilets per property (including previous owners). Customer further acknowledges that the rebate program is subject to available funds and may be cancelled at any time without notice. Rebate is available only for eligible customers and qualifying toilets as determined by the Metropolitan North Georgia Water Planning District. I have read and understand the toilet program policy as stated above. I understand to receive this rebate, I must install a qualifying toilet and dispose of my current toilet so that it may not be reused. I also understand a site visit may be conducted to verify toilet replacement. The original receipt for the new toilet purchased must be attached with this application for approval. I certify by my electronic signature below that I will comply with all of the requirements of the rebate program, that this application is true and correct in all respects, and that any failure on my part to provide true and correct information may subject me to penalties.Applicant's Signature*Please type your name in the box below. Signature Date* MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
