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2. Instructions
   1. The rebate(s) apply to new Consortium for Energy Efficiency (CEE) clothes washer with Integrated Water Factor (IWF) of 3.2 or lower purchased after 07/01/2012, new high-efficiency toilets purchased after 07/01/2012 that are for homes or businesses built in 1996 or older, and automatic evaporative (swamp) cooler thermostats purchased after 07/01/2015. 2. The completed Application form and itemized receipt must be received within 90 calendar days from purchase date. 3. Please ensure that you have read the Terms and Conditions on our website before you complete the application below.
6. Applicant Information
8. Name:*
9. Water Account # :*
10. Phone:
12. Installation Address*
13. Mailing Address:*
15. Type of Fixture(s) Installed ( Check all that apply):*

    1. HE Clothes Washer
    2. HE Toilet
    3. Evaporative Cooler Thermostat
19. Fixture(s) Details
21. HE Clothes Washer
23. Brand
24. Model Name
25. Model Number:
26. Purchase Date:
    Purchase Date:
28. Installation Date:
    Installation Date:
29. Purchase Price:
30. Number of Fixtures
34. HE Toilet
36. Brand:
37. Model Name:
38. Model Number:
39. Purchase Date:
    Purchase Date:
41. Installation Date:
    Installation Date:
42. Purchase Price:
43. Number of Fixtures Replaced:
47. Cooler Thermostat
49. Brand:
50. Model Name:
51. Model Number:
52. Purchase Date:
    Purchase Date:
54. Installation Date:
    Installation Date:
55. Purchase Price:
56. Number of fixtures replaced:
58. File Upload
62. Acknowledgement and Signature:
    I have read, understand, and agree to the terms and conditions of this agreement and the information contained in the application is truthful and correct to the best of my knowledge. I hereby certify that I am the customer authorized to replace the clothes washer, toilet, and/or evaporative cooler thermostat at the address listed above. I understand that providing false information may result in revocation of funds.
64. Applicant Signature:*
65. Date:*
    Date:
Leave This Blank:


67. Submit Submit and Print

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