2. Water Filter Rebate Program Application

   This application must be completed by the owner of the property where the water filtration system or water filters(s) will be installed.

4. First Name*
5. Last Name*
7. Property Address*
9. City*
10. State*
11. Zip*
13. Property Owner*

    Are you the owner of the property listed above?

    1. Yes
    2. No
15. Email Address*
17. Telephone Number*
21. FOR INTERNAL USE ONLY:

    Water Filter Rebate Program Assessment Process

    INSPECTIONS
    Date	Inspected by	NTU Measured	Comments

     

    I certify that this applicant qualifies for the Program for a rebate up to $1800.00

    DPW Director Signature______________________________

     

    Quote Received Date: ______________

     

    Installation Inspection Date: _________

    Inspected by: __________________________

     

    Receipts Received Date _______________

     

    We certify that this resident is entitled to receive a rebate of: $____________

     

    Signature Inspector            ______________________________________

     

    Signature DPW Director   ______________________________________

     

    Signature City Manager ______________________________________

Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit Submit and Print

* indicates a required field