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2. Irrigation Controller and Appliance Rebate Form
4. Applicant Name*
5. Do you pay the Town of Frederick directly for your water? *
   -- Select One --YesNo
7. Account Number*
8. Phone Number*
9. Email*
11. Installation Address*
13. Install City
14. Install State
15. Install Zip
17. Mailing Address*
19. Mailing City
20. Mailing State
21. Mailing Zip
25. Rebate Claims (Check all that apply):*

    1. WaterSense Certified Irrigation Controller : Cost of controller up to $200. Must be WaterSense Certified
    2. WaterSense Certified Toilet : $50 per toilet. Must be WaterSense Certified toilet with 1.0 gallons per flush (gpf) or less.
    3. Energy Star Certified "Most Efficient" Clothes Washer: $50 per clothes washer. Must be Energy Star certified "Most Efficient" Clothes Washer.

    Please fill out corresponding fields below...

27. Irrigation Controller/Toilet/Clothes Washer Brand:*
29. Irrigation Controller/Toilet/Clothes Washer Model Number:*
31. Number of Toilets Installed:
35. Copy of legal ID*
36. Receipt of purchase for installed item*
37. Upload photos of installed fixtures*
39. Legal Agreement*

    1. By checking this box, I certify:

    I have read and understand the conditions of eligibility for this rebate as stated in the program rules available on the Irrigation Controller Rebate, Toilet Rebate, and Clothes Washer Rebate webpages and understand that this rebate is conditioned upon my compliance with these terms. I understand that all documents, including receipts, become the property of the Town of Frederick once submitted, and the Town of Frederick reserves the right to randomly inspect my premise to verify the installation of my new fixture prior to issuing my rebate. I understand that the installation of a qualifying model does not guarantee a reduction in my water bill. This rebate is subject to the availability of funds and may be changed or discontinued without notice. I further acknowledge that making a false, fictitious, or fraudulent statement or representation is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statutes § 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received, pursuant to Colorado Revised Statutes § 26-1-127.

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41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

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