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645 Beacon Lite Road, Monument CO 80132 I p: [PHONE REDACTED] I email: [EMAIL REDACTED] Water Rebate Request Date of Application Date Service to Begin Service Address Homeowner Information: Name Mailing Address City State Zip Phone Number Email Address Rebate Checklist: ☐Town of Monument Water Account service address ☐Water Account is current ☐Application is complete and signed ☐Receipt is attached to application ☐New product purchased between 1.1.2024-12.31.2024 Check Rebate type/amount you are applying: ☐$50 Rain Barrel Rebate (limit 2 rebates per address) ☐$50 Toilet Rebate ☐$100 Irrigation Controller Rebate I certify that the above information is accurate, that I have read and conform to the program rules and qualifications, that the toilet and/or irrigation controller is installed and operational at this time. Homeowner Signature Date Below for Internal Use Only Amount Requested: Date Approved: Approved by: Date Applied to account: