Submit Your Rebate Application 1Contact, Billing, and Account 2Property Address 3Property Information 4Give Us Your Feedback 5Review & Submit Contact, Billing, and Account Data * Please enter name as it appears on utility bill. First name Last name Email address Phone Mobile In which city is the property? Please select one City Of Coconut Creek City Of Coral Springs City Of Dania Beach City Of Deerfield Beach City Of Fort Lauderdale City Of Hallandale Beach City Of Lauderhill City Of Margate City Of Pembroke Pines City Of Plantation City Of Sunrise Town Of Davie Town Of Hillsboro Beach What type of property is this? Please select one Residential Commercial/Business Institutional Not-for-profit Building type? Please select one Single family Townhouse Condo Duplex/Quad Multi-family Next Property Address Physical Address of Property Street address Ex. Apartment/unit number, suite #400, ... City Postal code Water Account Number Water utility billing address is same as property address. Water Utility Billing Address Street address Ex. Apartment/unit number, suite #400, ... City State Please select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Postal code Back Next Property Information Available Rebates If you are a residential applicant who resides in their single-family home, townhouse or condo in which the toilets are being replaced, you are limited to two rebates per qualifying applicant. Please indicate the number of rebates you are applying for: If you are a property owner or manager of a multi-family home(s), commercial business or industry, you can apply for up to five rebates, or request to receive more than five rebates. Please indicate the number of rebates you are applying for: Max rebate value per toilet: $0.00 Please select one 1 2 If you need additional rebates, tell us how many. Sub-division, development or complex name Do you own the residence where the toilet(s) will be replaced? Select one Yes No How many people reside in the home? How many people will be served by these rebates? Select one 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Number of full bathrooms? Please select one 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Number of half bathrooms? Please select one None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 How long have you lived at this address? (years) How long have you owned or managed this structure? (in years) Select one 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 Name of business or institution Do you own the commercial building(s) where the toilet(s) will be replaced? Do you own the multi-family complex where the toilet(s) will be replaced? Select one Yes, I am the Property Owner No, I am the authorized Property Manager No I do not own the residence(s) or the commercial building(s) where the toilet(s) will be replaced, but confirm that I have authority to apply on behalf of the owner or owning entity. If you are a property manager or management entity with authority and do not own the residence(s) or commercial building(s) where the toilets are being installed, provide the owner's information below. Please note that the owning entity will be contacted to verify approval: First name Last name Email address Company Phone Mobile Street address Ex. Apartment/unit number, suite #400, ... City State Please select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Postal code How many employees work in the building? Select one 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100 more than 100 Number of bathrooms? Please select one 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Number of toilets? Please select one 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 Year built? Please select one I don't know 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 Is the toilet(s) that you are replacing original to the home/structure? Please select one Yes No Maybe How many gallons per flush does/do the toilet(s) you are replacing use? You may find that information stamped on the space between the toilet seat and the tank or inside the tank itself. Or, please refer to Program Guidelines, Terms and Conditions to determine gallons per flush. List your entries. Ex. 2.5, 2.1, 5 Back Next Give Us Your Feedback How did you learn about this program? Website Utility bill message Flyer John Jacob Jingleheimer Schmidt Plumber/Contractor Business Card Bus Wrap Display Print Ad Newspaper Article Public Service Announcement (radio) Public Service Announcement (tv) Workshop HOA Friend/Family member Neighbor Other What website? Where did you see the flyer? What was the name of the event? What is the name of the individual/company? What display location? What publication? What newspaper? What radio station? What tv station? What location? HOA name? Other? Back Next Review Rebate Application I hereby certify that I am the property owner and the account holder or the property manager and have provided the account holder's contact information, of record for the address that I listed on this application; and that I have read and will abide by the Broward Water Partnership High-Efficiency Toilet (HET) Rebate Program Terms and Conditions for the rebate for which I am requesting approval. By checking this box you are certifying that you agree with the Broward Water Partnership High-Efficiency Toilet (HET) Rebate Program Terms and Conditions. Back