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2. Applicant first name*
3. Applicant last name*
5. Applicant address*
7. City*
8. State*
9. Zip*
11. Primary contact phone*
12. Email address
14. Installation address (if different from above)
16. Property type*

    1. Residential

    1. Commercial
20. Items purchased*

    1. Toilets: Must be EPA WaterSense labeled. Rebate maximum is $200 per toilet not to exceed 50% of the purchase price of each toilet. Maximum four toilets. Complete information on toilets below.
    2. Irrigation sprinkler bodies: Must be EPA WaterSense labeled. Rebate maximum is 75% of the cost of each sprinkler body, up to $10 per sprinkler body, limited to $100. Homeowners associations (HOAs) are not eligible for irrigation product rebates. Complete information on sprinkler bodies below.
    3. Irrigation controllers: Must be EPA WaterSense labeled. Rebate maximum is 50% of the purchase price of each irrigation controller up to $200. Homeowners associations (HOAs) are not eligible for irrigation product rebates. Complete information on irrigation controller below.
22. Rebate #1
24. Item purchased
    -- Select One --ToiletSprinkler bodyController
25. Date of purchase
    Date of purchase

    Must be purchased after July 1, 2024

26. Number purchased
    • Toilets limited to 4
    • Sprinkler bodies limited to 15
    • Irrigation controllers limited to 1
28. Make
29. Model name/number
31. Attach copy of receipt
33. Rebate #2
35. Item purchased
    -- Select One --ToiletSprinkler bodyController
36. Date of purchase
    Date of purchase

    Must be purchased after July 1, 2024

37. Number purchased
    • Toilets limited to 4
    • Sprinkler bodies limited to 15
    • Irrigation controllers limited to 1
39. Make
40. Model name/number
42. Attach copy of receipt
46. Customer Agreement*

    My signature indicates that the information provided is true, I have read and understood the rebate program guidelines, and that I comply with the City of Lakeville rebate program requirements. Upon compliance, a rebate will be distributed as a credit to my utility account if funding is available and my account is not delinquent at the time of application. I will allow a representative of the City of Lakeville to verify the installation if requested. Checking the box below will serve as my electronic signature.

    1. Signature

48. To receive an email copy of your completed form for your records, enter your email address in the field below before you click on the Submit button.

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50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

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