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2. Property Owner Name*
3. Email Address*
5. Phone Number*
7. Address*
9. City*
10. Zip Code*
12. Number of Toilets Replaced*
    -- Select One --12

    Maximum 2 toilets

13. Total Rebate Amount Requested*

    Not to exceed $100 pre-tax cost per toilet (Maximum $200)

15. Model Number*
16. Brand*
17. Serial Number*
18. Total Cost (before Tax)*
20. Toilet No. 2 Model Number
21. Toilet No. 2 Brand
22. Toilet No. 2 Serial Number
23. Toilet No. 2 Total Cost (before Tax)
25. Itemized Receipt *

    Maximum file size is 20 MB.

27. Photo of Installed Toilet No. 1*

    Your photo should include EPA WaterSense label and address verification, such as a piece of mail. Maximum file size is 20 MB.

28. Toilet No. 1 Additional Photo (if necessary)

    Use this space to upload an additional photo, if needed. Maximum file size is 20 MB.

30. Photo of Installed Toilet No. 2

    Your photo should include EPA WaterSense label and address verification, such as a piece of mail. Maximum file size is 20 MB.

31. Toilet No. 2 Additional Photo (if necessary)

    Use this space to upload an additional photo, if needed. Maximum file is 20 MB.

33. Acknowlegement of Terms & Conditions*

    I have read and accept the terms and conditions of this agreement and the information contained in this application is truthful and correct to the best of my knowledge. I hereby certify that I am a Woodbury resident with a residence connected to the City of Woodbury municipal water supply and that I have installed a US EPA WaterSense approved toilet at the residence. 

    I hereby certify that I am the customer authorized to replace the components listed above, and my components have been recycled or are otherwise legally disposed of and are no longer in service.

    Agree to Terms and Conditions?

     

    1. Yes
    2. No
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field