Single Family Residential Rebate Application Form
First Name / Company Name *
Installation Street Address: *
Zip Code *
Add Mailing Address (if different)
Mailing Street Address:
How did you hear about the rebate program?
Bill Insert (Pipeline)
Year home was built *
Must be built prior to 1996
No. of People
No. of Bathroom(s)
No. of Toilet(s)
No. of Showerhead(s)
No. of Faucet(s)
(Only EPA water-sense certified models are eligible -
substitutions will be accepted)
Toilet(s) Make / Model No.
Showerhead(s) Make / Model No.
Faucet(s) Make / Model No.
Attach Receipt *
By clicking submit, you agree to the
Rebate Agreement – Release of Liability Program Terms and Conditions
, you understand that you must properly dispose of any replaced fixtures so they cannot be reused