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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.
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.
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