Single Family Rebate Application

Single Family Toilet Rebate Application (Current)

Rebates are limited to customers of participating water systems and only for homes built before 1994. Only toilets that are Ultra High Efficient (UHET) using 1.1 gpf or less will be rebated at a value of $75. Dual-flush toilets (1.1/1.6 GPF) do not qualify. Toilets using 1.28 gpf are no longer eligible.

Prior to completing this form, make sure you have the following documents ready to submit:
- Receipt of purchase of your new toilet(s)
- Recent water bill that clearly displays the account number and the metered address.
- Note: The rebate is applied to the property account address stated on the provided water utility bill. Only customers up-to-date on their bills are eligible.
Customer Information
Customer Name*
First Last
Email Address*
Telephone
Please 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:*
Street Direction:
City:*
Zip 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 Number
Insert street number here.
Mailing Address Street Name:
Mailing Address Street Designation:
Mailing Address Street Direction:
Mailing Address City:
Mailing Address State
Mailing Address Zip Code:
Insert zip code only.
Water Utility:*
If your water utility is not listed, they do not currently participate in our Toilet Rebate Program and you are not eligible for the rebate.
Utility Billing Account #*
Receipt of Purchase*
Please upload the following documents:
- - Receipt of purchase of new toilet(s)
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.
Current Water Bill*
Please upload the following documents:
- - Recent water bill that clearly displays the account number and metered address
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.
How did you hear about the program?
- Friend
- Retailer/Plumber
- Water Bill Insert
- Website
Household Information
Only single-family residential homes built in 1993 or earlier with toilets using 3.5 gpf or greater are eligible.
Number of people in the household:
Please enter a number from 1 to 10.
Year home was built (must be before 1994):*
Please enter a number from 1900 to 1993.
Homes built 1994 or later are not eligible for the rebate. Homes must have been built in 1993 or earlier.
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 Information
How 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.
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. 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.
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. 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.
What 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.
Model 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
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Email
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Single Family Rebate Application

Single Family Toilet Rebate Application (Current)

Customer Information

Household Information

Toilet Information

Toilet Program Policy: