APPLICANT FIRST NAME
APPLICANT LAST NAME
WATER ACCOUNT NUMBER
BUSINESS OR HOA NAME (IF APPLICABLE)
YOUR EMAIL
INSTALLATION ADDRESS
CITY
ZIP
NEW TOILET INFORMATION: MAKE(S) AND MODEL NUMBER(S) INSTALLED
TOILET 1
MAKE
MODEL
TOILET 2
TOILET 3
TOILET 4
TOILET 5
NUMBER OF REBATES REQUESTED
OLD TOILET INFORMATION(This section must be completed for eligibility.)
NUMBER OF TOILETS AT INSTALLATION ADDRESS
PROVIDE THE AGE IN YEARS OR THE DATE OF MANUFACTURE OF THE TOILET(S) BEING REPLACED. THIS IS SOMETIMES FOUND ON THE INSIDE SURFACE OF THE TOILET TANK OR LID.
OR, IF AGE IS UNKNOWN, YEAR HOME WAS BUILT
CHECK PAYEE INFORMATION(required only when the applicant does not pay the water bill) MAKE CHECK PAYABLE TO
ADDRESS
Upload Receipts
PLEASE REVIEW THE APPLICATION CHECKLIST (ABOVE, RIGHT) BEFORE SIGNING THE APPLICATION. I HAVE READ, UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS OF THIS REBATE PROGRAM.
DISCLAIMER: The undersigned expressly agrees that COACHELLA may inspect all properties participating in the Toilet Replacement Rebate Program; that COACHELLA does not guarantee the performance of any toilet; and that COACHELLA does not warrant any toilet or installation to be free of defects; the quality of workmanship, or the suitability of the premises or the toilet for the installation. The undersigned further agrees to defend, indemnify and hold harmless COACHELLA, its directors, officers, agents, and employees, from and against any and all loss, damage, expense, claims suits and liability, including attorney’s fees arising out of or in any way connected with the toilet(s) and its (their) installation. Applicant has read, understands and agrees to the terms and conditions listed on the High-Efficiency Toilet Rebate Program application. Applicant understands that installation of a qualifying low flow toilet may not result in lower water bills. COACHELLA reserves the right to add or remove eligible toilets from the list or change the terms of the incentive offer at any time. PLEASE REVIEW
SIGNATURE OF APPLICANT
DATE
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