Form Center

Water Efficiency Rebate Request

2. Applicant Information

4. Applicant First Name*

5. Applicant Last Name*

7. Applicant Address*
   Address

9. City*

10. State*

11. Zip*

13. Primary Contact Phone*

    Include area code with no dashes

14. E-Mail*

16. Installation Address (if different from above):

18. Property Type*

    1. Residential

    1. Commercial

22. Water Utility Information

24. Rebates are only available to City of Apple Valley utility customers with non-delinquent accounts.

26. Water Utility Bill Account #*

28. Water Utility Bill Customer #*

32. Installation Information
    The City reserves the right to inspect the products for proper installation.

    The City reserves the right to inspect the products for proper installation.

34. Items Purchased*

    1. 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.
    2. Washing Machine: Must be US DOE Energy Star labeled. Rebate is $150 per washing machine. Fill out information on washing machine below.
    3. 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.
    4. 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.

36. Date of Purchase - Rebate #1
    Date of Purchase - Rebate #1

    must be purchased after January 1, 2020

38. Information Required for Toilet, Washing Machine, Irrigation Controller Rebate

40. Make

42. Model

44. Attach Copy of Receipt

46. To request another rebate, Choose here
    -- Select One --ToiletWashing MachineIrrigation AuditIrrigation Controller

48. Date of Purchase - Rebate #2
    Date of Purchase - Rebate #2

    must be purchased after January 1, 2020

50. Make - 2nd Rebate

52. Model - 2nd Rebate

54. Attach Copy of Receipt for 2nd Rebate

58. Information Required for Irrigation Audit Rebate

60. Date of Audit
    Date of Audit

    Audit must be completed after Jan 1, 2020

61. Date of Installation
    Date of Installation

63. Name of Irrigation Professional

65. Name of Irrigation Company

67. Attach Copy of Receipt

69. Attach Copy of Audit

73. 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.

    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.

75. I agree*

    1. I agree

77. Electronic Signature*

    "First M. Last"

Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

* indicates a required field