TOWN OF CARY
PUBLIC WORKS AND UTILITIES DEPARTMENT

ATTN: HET REBATE PROGRAM
P.O. Box 8005
Town of Cary, NC 27512
(919) 469-4090

Non-Residential High Efficiency Toilet Retrofit Rebate Program Application

APPLICANT INFORMATION- PLEASE PRINT

NAME: ________________________________ TAX ID #:______________________
ACCOUNT #: _________________________

BILLING ADDRESS (check mailed here): ________________________________________________________________________

SERVICE ADDRESS (if different): ______________________________________________________________________________

CITY:_____________________________ STATE:__________ ZIP:____________ PHONE:_______________________________

EMAIL: _________________________________________________ Preferred method of contact (circle one) EMAIL PHONE

REBATE PROGRAM INFORMATION- PLEASE PRINT

Complete information about each toilet retrofit below- limit five rebates per non-residential account.

Provide either current toilet size, make and model- Make & model of new toilet Fixture price Date installed

or the height, width and depth of water level in tank

1. ___________________________________ _______________________ ____________ ___________

2. ___________________________________ _______________________ ____________ ___________

3. ___________________________________ _______________________ ____________ ___________

4. ___________________________________ _______________________ ____________ ___________

5. ___________________________________ _______________________ ____________ ___________

I have read and understand the rebate policy as stated in the program guidelines and I agree to a site visit by a Town of Cary staff person for verification purposes.

SIGNATURE OF APPLICANT:________________________________________________ DATE:__________________________

FOR OFFICE USE ONLY

APPROVED (circle): 1 2 3 4 5 REBATE AMOUNT (circle):

Reason for disapproval: $100 $200 300 $400 $500

SIGNED: _______________________________________________ DATE:____________________

Water Conservation Technician

APPLICATION INSTRUCTIONS:

1. Confirm your old toilet is eligible by either: (refer to program guidelines)

· Providing the size, make and model stamped on the toilet, or

· Measuring the height, depth and width of the water level (when full) in the tank.

Purchase and install WaterSense approved high efficiency toilet(s).

Complete the appropriate rebate application. There are two applications, one for residential accounts and one for non-residential accounts.

MAIL a completed application with original dated receipt(s) attached to the address above.

A Town representative will contact you to schedule a site visit to verify installation. A check will be mailed to the applicant within 4 weeks of the site visit approval.For additional assistance, please call (919) 469-4090.