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2. How to Apply and Program Rules:
   • Purchase and install a qualifying High-Efficiency Toilet. Click here for a list of qualifying toilets. The models listed were chosen for their efficient use of water.
   • The product must be purchased after April 1, 2010. A rebate application must be submitted in the same year the toilet was purchased. Example if you purchased your toilet on July 15, 2010, you must submit your rebate application by December 31, 2010.
   • The purchased toilet must be for use at an address that receives water service from the Town of Firestone. Residents of other cities and/or customers of other water providers are not eligible. A Town of Firestone water account number is required.
   • Rebates can be filed by property owners and renters. Contractors or anyone else working with a property that they do not own cannot apply for a rebate. The property owners or renters are responsible for installation.
   • The Town reserves the right to inspect the installation of any appliance for which a rebate is provided.
   • One of each type of rebate per household and one of each type of rebate per household within a five-year period.
   • The original copy of the sales receipt must be attached to the application and include the date of purchase, price, brand name, model number, and serial number. Please keep a copy of the receipt for your records or apply in person to keep your original.
   • A photograph of the installed toilet is required. As well as, a photograph of the replaced toilet broken after being removed is required.
   • All blank fields below need to be completed for the application to be processed.
   • Rebate program availability will be on a first-come, first-served basis.
   • Once all the above steps are completed, the Town of Firestone will issue applicants a rebate. Please allow up to six to eight weeks to receive the rebate.
6. Water Account Number*
8. First Name*
9. Last Name*
11. Property Street Address*
13. Mailing Address*
15. City*
16. State*
17. Zip*
19. Subdivision*
20. Email*
22. Home Phone*
23. Cell Phone
25. Purchase Date for Toilet (mm/dd/yy)*
26. Installation Date for Toilet (mm/dd/yy)*
28. Toilet Manufacturer*
29. Estimated Age of Toilet Being Replaced
31. Toilet Model Number*
32. Toilet Serial Number*
34. Number of Bathrooms in the Home*
35. Number of People Living in the Home*
37. Scan of Appliance Receipt of Purchase*
38. Photo of Destroyed Toilet*
39. Photo of Installed Toilet*
41. Check Here*

    1. I agree my electronic submission of this form constitutes my signature affirming the above information is true and correct.
43. Signature*
44. Date*
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit Submit and Print

* indicates a required field