ultra low flush toilet rebate application - Golden State Water Company

GOLDEN STATE WATER COMPANY TOILET REBATE APPLICATIONImportant: Please read the application materials carefully and keep a copy for your records. Please type or print clearly in ink, then mail completed application andoriginal cash register receipt and/or plumber's invoice to the water provider listed below. Use one application per property location. Residential, commercial, industrialinstitutional and multi-family applicants are eligible. The number of rebates is dependent upon the availability of program funds. All information on this application form isconsidered confidential. Applications are processed in the order received. Funding is limited, therefore, rebates are not guaranteed.WATER ACCOUNT NUMBERASSESSOR'S PARCEL NUMBERAPPLICANT NAME (REBATE CHECK PAYABLE TO) SSN / FED. TAX IDENTIFICATION (ID) (only necessary if the rebate amount s sum exceeds $600)COMPANY NAME (BUSINESSES ONLY)APPLICATION DATEPHONE PHONE (EVE) BEST TIME TO CALLMAILING ADDRESYEAR BUILTCity STATE ZipName and address of property where toilets will be installed:PROPERTY / SITE NAME (IF APPLICABLE)ADDRESS CITY ZIPNUMBER OF TOILETS ON PROPERTYNUMBER OF TOILETS FOR REBATEMAKE(S) AND MODEL(S) REMOVEDMAKE(S) AND MODEL(S) INSTALLEDFLUSH VOLUMEFLUSH VOLUMEgGPF (gallons per flush)GPF (gallons per flush)TYPE OF PROPERTY: House Apartments (No. of units_______) Mobile Home Townhouse / Condominium Business / Commercial Schools and InstitutionsQUANTITYQUANTITYAre you the water bill recipient for the account number listed above? Yes NoIf NO, please provide the name and phone number of the water bill recipient.WATER BILL RECIPIENT NAMEPHONE NUMBERAGREEMENTI have read and understand the program information as stated in the attached application materials. I certify that I have installed said toilet(s) at thesubject property. I also understand that by signing here I agree to have an official of my water provider verify the installation of the ultra-low flushtoilet(s) at said property. I agree to hold _____________________________________Golden State Water Company, Sacramento RegionalCounty Sanitation District, and the Regional Water Authority harmless from any and all liability or claims for damage resulting from or alleged toresult from the installation of the ULFT, the inspection of the premises to verify proper installation, and any other activity related to this program.AUTHORIZED SIGNATURE TITLE (IF APPLICANT IS A BUSINESS) DATEMail the application and original cash register receipt and/or plumber's invoice to the address listed below. For more information, call Golden StateWater Company at the number below.Send application to:Golden State Water Company at:Water Conservation Coordinator1920 West Corporate WayAnaheim, CA 928011-800-999-4033FOR OFFICIAL USE ONLYAPPLICATION ID (For internal use only):Application received byDate received Approved Denied Reason for denialToilets ________ Rebate amountSRCSD amount _________ Original receipt __________________________________________INSPECTION — Required Waived Performed by Date inspected Approved Denied Reason for denialRebate request sent to RWA by:Date:

How to get your high efficiency toilet (HET)rebate.1. You must first call Golden State Water Company @ 1 800999-4033 to see if rebates are available.2. To obtain a rebate, customers must agree to a Water- WiseHouse Call. This service is at no direct cost to thecustomer.3. Purchase and install the new toilet(s). You must bereplacing a toilet using 3.5 gallons per flush or greater to beeligible.4. You may install the toilet(s) yourself or you may also hire alicensed contractor.5. Return the original dated receipt and/or plumber’s invoicewith the price, model and brand of each toilet listedindividually, and the completed application. Keep a copy foryour records.6. Submitting a signed application represents agreement tohave Golden State Water Company verify installation of thetoilet, with your accompaniment. Golden State WaterCompany will schedule an inspection.7. Rebates are up to $175 for an HET (High Efficiency Toilet).Call Golden State Water Company to verify the amount youare eligible for. Total rebate amount will not exceed moneyspent.Eligible expenses include 1.28 gallon per flush tank, bowl,seat, supply line, wax ring, caulking, bolts, bolt covers, andtax.8. Golden State Water Company will issue rebate checkswithin eight to ten weeks of receipt of your completedapplication materials.9. Golden State Water Company is required to send IRS form1099 to the customer and the IRS when rebates total $600or more.Qualifications1. Purchase of material must occur within the program periodof January 1, 2011 to December 31, 2011. The number ofrebates is dependent upon the availability of program funds.Call Golden State Water Company to see if funds areavailable.2. The location of installation must be served by Golden StateWater Company.3. Residential, commercial, industrial, institutional and multifamilyapplicants are eligible.4. Replacement of a ULFT with an HET is not eligible forrebate under this program.5. New construction is not eligible for rebate under thisprogram.PermittingBuilding permits are not required when a residential customersimply removes and installs a toilet on existing plumbing. Apermit is required when a plumbing fixture will be relocated oryou are a business customer.DisclaimerGolden State Water Company, the Regional Water Authority(RWA), and the Sacramento Regional County Sanitation District(SRCSD) reserve the right to deny an application of anyparticipant who does not meet all requirements as outlined. TheRWA, Golden State Water Company, and the SRCSD reservethe right to change the terms of this program at their discretion.The RWA, Golden State Water Company and the SRCSD arenot responsible for receipts or paperwork lost in the U.S. mail.The RWA, Golden State Water Company and SRCSD cannotguarantee that the installation of the HET’s will result in lowerwater utility costs. The number of rebates is dependent upon theavailability of program funds. Applications will be processed,when all required information is provided by the applicant; on afirst-come, first-served basis.Customer SurveyThis rebate program is partially funded through a grant from theCalifornia Department of Water Resources. As part of thatprogram, we are surveying customers to understand why theyare making their choices regarding the replacement of toiletfixtures. In order for your rebate to be processed in a timelymanner, please complete the following questions:1. Toilets are being installed in a:HomeBusiness2. How many toilets do you havein your home or business? If abusiness, please specify numberof urinals also.3. How many toilets are beingreplaced?4. For efficient toilets alreadyinstalled in the home, how wouldyou rate their performance?Better than expectedAbout what expectedBelow what expectedDon’t yet know5. Primary reason for replacingexisting toilet with a moreefficient toilet (please check onlyone).Bathroom remodelToilet broken or notperforming wellHeard about the rebateprogramConcerned about savingwaterOther6. If there are toilets in thehome/business that are notbeing replaced, (please check allreasons that apply below). Toilet is already 1.6 gallonsper flush or less Existing toilet is workingwell New toilet too expensiveOther7. Would you consider replacingany toilets that are not efficient(greater than 1.6 gallons perflush) in the next 2 years ifadditional rebates are available?YesNo8. For those purchasing a 1.6gallons per flush toilet, pleasecheck all reasons that apply fornot choosing a higher efficiency1.28 gallon per flush or lesstoilet. Didn’t know about them Didn’t like the selectionavailable Concerned about theirperformance (too new tomarket) Too expensive compared tothe 1.6 gallons per flushmodelsOther9. How did you find out about theprogram? (Please check all thatapply):Utility billing/NewsletterNewspaper/PublicationRadio/TVBillboardAt an eventFriend/NeighborOther