Residential Water Efficiency Rebate Form • City of Thornton

Applicant Information

Applicant name

Do you pay Thornton directly for your water?

Where can I find my account number and customer number? They are located on your Thornton utility bill.

Click here to view an example utility bill.

Account number

Customer number

Installation address

City

State

Zip

Mailing address

City

State

Zip

Phone number

Where did you hear about Thornton’s water efficiency rebate program?

Rebate claims

I have read and accept the rebate rules. Detailed rules and eligibility available at ThorntonWater.com.

WaterSense Certified Irrigation Controller: The cost of the controller up to $200. Limit one per 10 years. Must be a WaterSense certified irrigation controller.

Controller model number

Cost of controller

Did you purchase your product in a Thornton store?

Rain Sensor: $25. Limit one per 10 years.

Rain sensor model number

Did you purchase your product in a Thornton store?

WaterSense Certified Toilets: $75 per toilet. Limited to number of bathrooms listed on Adams County records. For replacement of installed toilets only, not for new construction. 1.6 gallons per flush toilets do not qualify. Must be WaterSense certified toilets. Standard 1.6 toilets do not qualify for the rebate program. New in 2020 - Dual flush toilets on the WaterSense list do not qualify for a rebate.

Toilet model number(s)

Number of certified toilets installed

Yes, I have discarded or recycled the old toilet(s).

Did you purchase your product in a Thornton store?

Attachments

The following attachments are required for us to process your form. Without them we cannot give out rebates.

Copy of applicant's legal ID
Photos of installed fixture(s)
Legible copy of receipt(s), to include:
- Brand/model number
- Price
- Date of purchase

Copy of applicant's legal ID

Choose one or more files to upload.

Photos of installed fixture(s)

Choose one or more files to upload.

Legible receipts of installed fixture(s)

Choose one or more files to upload.

Residential Water Efficiency Affidavit

I, the applicant, have read and understand the conditions of eligibility for this rebate as stated in the rebate rules available on ThorntonWater.com. This rebate is conditioned upon my compliance with its terms and with the terms required by the City of Thornton. I understand an inspection may be scheduled with a City inspector to verify installation of the water efficient fixture. I also understand that the City of Thornton makes no representations or warranties regarding any make or model of approved fixtures, including any warranties of merchantability or fitness for a particular purpose or water efficiency. The City of Thornton is not liable or responsible for any act or omission of any contractor whatsoever, nor is the City of Thornton responsible for the condition of the plumbing and electrical wiring on the homeowner’s side of the meter now or in the future. This rebate is subject to availability of funds and may be changed or discontinued without notice. I also understand that I am responsible for installation of the new fixture and disposal of the old fixture.

Affidavit of lawful presence in the U.S.
(A requirement of Colorado Law - HB 06S-1023)

I, the applicant, swear or affirm under penalty of perjury under the laws of the State of Colorado that I am a:

Citizen status

I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.

I, the applicant, have read and accept the affidavit.

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