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City of Auburn WaterSense® Toilet Rebate Program The City of Auburn WaterSense® Toilet Rebate Program provides customers up to a $100 rebate per toilet for the replacement of up to two
old toilets with new high-efficiency toilets with the WaterSense® label. Instructions and Requirements 1. The toilet you purchase must bear the WaterSense® label. 2. You must be a current
Auburn Water Customer. 3. The rebate application must be submitted within 90 days of toilet purchase. 4. The toilet(s) must be installed at a site with an Auburn Water account, not including
irrigation accounts. 5. Old toilets should be recycled or disposed. They may not be resold or reused. 6. Include a copy of your water bill with your application. 7. Include a copy of
your receipt, not a product order form or estimate. If the receipt doesn’t indicate the specific model of the toilet, provide other documentation, such as the WaterSense® label or model
number from the packaging or a copy of the owner’s manual. 8. Include a completed Department of Treasury Internal Revenue Service Form W-9 9. Complete one application form for up to
two rebates and return it and attachments by mail to: City of Auburn, Water Quality Programs Coordinator, 25 West Main, Auburn, WA 98001 10. The rebate amount is the pre-tax purchase
price of each toilet or $100, whichever is lower, for a maximum of $200. The rebate covers the cost of the toilet only. Additional parts required for installation, labor charges or tax
are not eligible for rebate. 11. Incomplete applications or applications lacking requested documentation will not be processed. 12. Auburn reserves the right to inspect properties to
confirm installation before rebates are issued. 13. This program is dependent on funding and may terminate without prior notice. 14. Please allow 4 – 6 weeks to receive your rebate check.
Please Write Legibly Last name: First name: Mailing address: Service address (if different): Phone: Number of full time residents: Year residence or building was constructed: Number
of WaterSense® labeled toilets purchased and installed at this residence: New toilet brand and model: Please check to indicate that you have completed the following tasks: ı I have included
a copy of the receipt of other material that clearly shows I purchased a WaterSense® labeled toilet. ı I installed the new toilet in a building which is served by the Auburn Water Utility.
ı I am submitting this application within 90 days of purchase of toilet. ı I have provided a copy of my water bill. ı I have included a completed Department of Treasury Internal Revenue
Service Form W-9 ı I have indicated the new toilet brand and model above. ı My account is in good standing with the Auburn Water Utility. “I certify that the information above is correct
and accurate. I understand that the Auburn Water Utility makes no warranties or guarantees regarding any toilets purchased under this program or any promises of water savings or reduction
on my water bill. Auburn is not responsible for any problems or damages to my property resulting from the installation of a new toilet. I understand that if I didn’t purchase an eligible
toilet model or if the Auburn Water Utility is not my water provider, this application will be denied.” Signature: Date: