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Residential High Efficiency Toilet - Rebate Program Application 7/1/17 - 6/30/18

  1. Providing an Email address will speed up the response time to your application.

  2. Are you the Property Owner?*

  3. Have you previously applied for this rebate?*

  4. Attach to application

  5. Please provide the following if legible. (Manufacturer date/model is usually found stamped under the inside of the toilet lid or back of tank)

  6. How many gallons per flush (GPF) does the NEW toilet(s) purchased use? (Ask retailer if unsure)

  7. (Separate application required for each address)

    • When the completed application is approved, an appointment may be scheduled for a brief visual inspection by the City.
    • The rebate value may not exceed the actual cost of the toilet(s).
    • An original itemized dated sales receipt is required to qualify for the rebate.
    • Limit of up to 3 toilets per account per fiscal year (July 1, 2017 - June 30, 2018).
    • Rebate application must be received within 60 days of sales receipt.
    • Compliance with the attached guideline is required.
  8. The City of Modesto may deny any application that does not meet program requirements. The undersigned expressly agrees that the City may inspect all items submitted for the High Efficiency Toilet Rebate Program. The City does not guarantee the performance of any toilet; does not warrant any toilet or installation to be free of defects, the quality of the workmanship, or the suitability of the premises or the toilet for installation. The undersigned further agrees to hold harmless the City of Modesto against all loss, damage, expense, and liability resulting from the loss, destruction or damage to property arising out of or in any way connected with installation of a toilet. The City reserves the right to alter this program at any time. Funding for this rebate program is limited to available resources. Rebates are processed on a first come, first served basis. For further information, please call (209) 342-2246.

  9. Electronic Signature*

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