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Middleton Water Utility High Efficiency Toilet Rebate Residential Application Form Please read all program rules before submitting. The rules can be found at www.cityofmiddleton.us/waterconservation. Applicant Information Name (please print) Account Installation Address Unit Number Mailing Address (if different) Mailing Address City State Zip Telephone Number of bathrooms in home Number of people in home Old Toilet Information Estimated tank size of toilet (gallons) being replaced (check one): o 1.6 gallons per flush o 3.5 gallons per flush o 5 gallons per flush New Toilet Information New toilet manufacturer (brand) Model name Model number Purchase price Rebate Agreement o I have read, understand, and agree to the terms and conditions in the Toilet Rebate Program description. The toilet I have purchased complies with the City of Middleton Plumbing Code and the City of Middleton Cross Connection Ordinance. I understand that I must dispose of the recycled toilet so it cannot be reused. I understand and agree that the Middleton Plumbing Inspector upon prior notification to me may inspect the premises to verify installation of the rebated WaterSense toilet (one per household per year). Applicant Signature Date Mail your completed application form and your original dated receipt to: Middleton Water Utility, Water Conservation Rebate Program, 7426 Hubbard Avenue, Middleton, WI 53562. Questions? (608) 821-8370