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Water Efficiency Rebate Request
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This form has been modified since it was saved. Please review all fields before submitting.
Applicant Information
Applicant First Name
*
Applicant Last Name
*
Applicant Address
*
Address
City
*
State
*
Zip
*
Primary Contact Phone
*
Include area code with no dashes
E-Mail
*
Installation Address (if different from above):
Property Type
*
Residential
Commercial
Water Utility Information
Rebates are only available to City of Apple Valley utility customers with non-delinquent accounts.
Water Utility Bill Account #
*
Water Utility Bill Customer #
*
Installation Information
The City reserves the right to inspect the products for proper installation.
Items Purchased
*
Toilets: Must be EPA WaterSense labeled. Rebate Maximum is $100 per toilet not to exceed 50% of the purchase price of each toilet. Fill out information on toilet below.
Washing Machine: Must be US DOE Energy Star labeled. Rebate is $150 per washing machine. Fill out information on washing machine below.
Irrigation Audit: Audit must be done by an Irrigation professional certified by a US EPA WaterSense program. $150 Rebate per Audit. Fill out Audit information below.
Irrigation Controller: Must be EPA WaterSense labeled. Rebate maximum is $150 per controller not to exceed 50% of the purchase price of each controller. Fill out information on controller below.
Date of Purchase - Rebate #1
Date of Purchase - Rebate #1
must be purchased after January 1, 2020
Information Required for Toilet, Washing Machine, Irrigation Controller Rebate
Make
Model Number
Attach Copy of Receipt
To request another rebate, Choose here
-- Select One --
Toilet
Washing Machine
Irrigation Audit
Irrigation Controller
Date of Purchase - Rebate #2
Date of Purchase - Rebate #2
must be purchased after January 1, 2020
Make - 2nd Rebate
Model Number - 2nd Rebate
Attach Copy of Receipt for 2nd Rebate
Information Required for Irrigation Audit Rebate
Date of Audit
Date of Audit
Audit must be completed after Jan 1, 2020
Date of Installation
Date of Installation
Name of Irrigation Professional
Name of Irrigation Company
Attach Copy of Receipt
Attach Copy of Audit
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
Customer Agreement: My signature indicates that the information provided is true, I have read and understood the rebate program guidelines, and that I comply with the City of Apple Valley rebate program requirements. Upon compliance, a rebate will be distributed as a credit to my utility account if funding is available and my account is not delinquent at the time of application. I will allow a representative of the City of Apple Valley to verify the installation if requested.
I agree
*
I agree
Electronic Signature
*
"First M. Last"
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