2. MARIETTA POWER AND WATER TOILET RETROFIT REBATE PROGRAM

   Rebates are limited to single-family, residential customers receiving water service from Marietta Power and Water (MP&W). Rebates are only offered for homes built prior to 1994. Rebates shall be a one-time credit applied to the customer's Marietta Power and Water bill as $75 for the purchase of WaterSense ultra high efficiency toilet(s) rated at 1.1 GPF or less. On or after July 1, 2021, no other toilets qualify for the rebate program.

4. Rebate eligibility checklist (you must check ALL to be eligible):*

   1. My home was built before 1994.
   2. I am a residential customer receiving water service from Marietta Power and Water.
   3. I do not pay my bill through a home owner's association or condo association (my bill comes directly from MP&W).
6. Customer and Location Information
8. First Name*
9. Last Name*
10. Billing Account Number*
12. Address*
13. Zip Code*
14. Phone Number*
    Day-Time Phone Number
16. Email Address*
17. Year Home Built*

    House must be built before 1994 to qualify

21. Toilet Information
22. Total number of toilets replaced on this application*

    1. 1
    2. 2
    3. 3

23. RECENT PROGRAM CHANGE: Toilets purchased on or after July 1, 2021, must be WaterSense labeled ultra high-efficiency toilets (Water Sense UHET) using 1.1 GPF or less to be eligible for rebate(s) of $75. No other toilet(s) will be considered for rebate(s) on or after July 1, 2021.

25. What is the GPF of your OLD toilet #1?*
    -- Select One --5.0 GPF or higher3.5 GPF1.6 GPF1.28 GPF
26. What is the GPF of OLD toilet #2?
    -- Select One --5.0 GPF or higher3.5 GPF1.6 GPF1.28 GPF
27. What is the GPF of OLD toilet #3?
    -- Select One --5.0 GPF or higher3.5 GPF1.6 GPF1.28 GPF

    Maximum of three (3) toilets per location including previous owners
29. What if the GPF of NEW toilet #1?*
    -- Select One --Single flush 1.28Single flush 1.2Single flush 1.1Single flush 0.8Dual flush 1.1/1.6Dual flush .08/1.28
30. What is the GPF of NEW toilet #2
    -- Select One --Single Flush 1.28Single Flush 1.2Single Flush 1.1Single Flush 0.8Dual Flush 1.1/1.6Dual Flush 0.8/1.28
31. What is the GPF of NEW toilet #3
    -- Select One --Single flush 1.28Single flush 1.2Single flush 1.1Single flush 0.8Dual flush 1.1/1.6Dual flush .08/1.28
33. Model number of NEW toilet #1
34. Model number of NEW toilet #2
35. Model number of NEW toilet #3
37. Date of purchase NEW toilet #1*
    Date of purchase NEW toilet #1
38. Date of purchase NEW toilet #2
    Date of purchase NEW toilet #2
39. Date of purchase NEW toilet #3
    Date of purchase NEW toilet #3
41. Receipt of Purchase*

    Upload receipt(s) of purchase for new toilet(s). Receipt(s) may show purchase of more that one toilet. 

42. Additional Receipts
43. Additional Receipts
47. Toilet Rebate Policy acknowledgement and signature

49. By my signature below and submittal hereof, customer acknowledges that the rebate is a one-time rebate to be received only if the customer has purchased eligible toilets after July 1, 2019 and is in good financial standing with the Marietta Power and Water. Customer acknowledges their home was built prior to 1994 or earlier with toilets using 3.5 GPF or greater. Customer also acknowledges that the credit is only available for WaterSense labeled ultra high efficiency toilets ($75 for 1.1 GPF or less) with a maximum of three (3) toilets per property (including previous owners). Customer further acknowledges that the rebate program is subject to available funds and may be cancelled at any time without notice. Please allow eight (8) weeks for processing. I have read and understand the toilet program policy as stated above. I understand to receive this rebate, I must install a qualifying toilet and dispose of my current toilet so that it may not be reused. I also understand a site visit may be conducted to verify toilet replacement. The original receipt(s) for the new toilet purchased must be attached with this application for approval. I certify by my electronic signature below that I will comply with all of the requirements of the rebate program, that this application is true and correct in all respects, and that any failure on my part to provide true and correct information may subject me to penalties.

51. Applicant's Signature*
52. Signature Date*
    Signature Date
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit Submit and Print

* indicates a required field