Please print clearly to ensure prompt response.
W
ater Utility Account #__________________ Owner occupied Renter occupied (Renter responsible for utilities)
N
ame (print) ________________________________ Work Phone _______________ Home Phone_______________
Installation Address ___________________________________________________________ Zip Code ___________
Mai
ling Address (if different) ____________________________________________________ Zip Code ___________
E-m
ail __________________________
_
Preferred Method of Contact: ___Work Phone ___Home Phone ___ Email ___ Mail
Y
ear home was built __________ Number of older generation toilets to be replaced: 1 2 3
Toilets:
Number of toilets in home _____
H
ave any toilets in the home already been updated to a low-flow type? Yes No
If ‘Yes,’ how many? _______ How many replaced as part of ACSA toilet rebate program? _______
N
OTE: If your home was built after 1992, the ACSA must verify that the toilet(s) being replaced is/are older
generation. If, in fact, the toilet(s) is/are not older generation, it/they will NOT be picked up and you will NOT be
eligible for a rebate. Please note that the new toilet(s) must be 1.6 gallons per flush or less to qualify.
NEW TOILET INFORMATION
1. T
oilet Purchase Price _______________ Toilet Seat Price _____________ Total Reimbursable Costs __________
2. T
oilet Purchase Price _______________ Toilet Seat Price _____________ Total Reimbursable Costs __________
3. Toilet Purchase Price _______________ Toilet Seat Price _____________ Total Reimbursable Costs __________
Confirmation or denial of approval for the program will be sent to you via mail. If
you are approved for the program, upon receiving approval, you will need to call
our office to arrange pick-up of your old toilet(s). Our pick-up day is every
Thursday. Please call BEFORE Thursday. If you call ON a pick-up day, your pick-
up will not be scheduled until the following pick-up day. Funding for the rebate
program is limited, and rebates are awarded on a “First-Come, First-Served” basis.
A rebate is not guaranteed unless all program requirements are met and you have
received confirmation of approval.
I certify that all eligibility requirements have been met, and that an itemized, original receipt has been submitted to
the ACSA.
Customer Signature ____________________________________________________
P
lease return completed form to the ACSA Toilet Rebate Program, 168 Spotnap Road, Charlottesville, Virginia 22911 or email
toiletrebate@serviceauthority.org
Albemarle County Service Authority
Toilet Rebate Form for Residential Customers
Application #___________
Required Qualifying Information
For ACSA Use Only
Approved: Yes_____ No_____
Approved by: _______________
Due Date: __________________
Denial Reason:
___________________________
___________________________
___________________________
