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2. Review requirements and Charlottesville Toilet Rebate Information.
   Charlottesville Toilet Rebate Program Details

   The Charlottesville Toilet Rebate Program is a rebate of up to $150 per toilet which includes the cost of the toilet and installation costs.

   Eligible toilets for the $150 rebate must have been purchased or installed on or after October 1st, 2024. 

   Any toilets purchased or installed before October 1st, 2024, must meet the old toilet rebate program requirements (replacing toilet used 3+ gpf). 

   We will rebate up to a maximum of 3 toilets per household including any rebate requests of the old toilet rebate program. 

3. 
5. First Name*
6. Last Name*
8. Service Address*
9. Service Address Zip Code*
11. Mailing Address*

    Put "Same" if your service address is the same as your mailing address.

13. Phone Number*
14. Email*
15. Water Account Number*
17. Old Toilet Gallons Per Flush Volume (gpf)*
    -- Select One --3.5 or more gallons per flush1.6 to 3.5 gallons per flushLess than 1.6 gallons per flushI Don't Know
19. New Toilet Brand, Make, and Model*
21. Number of Toilets Purchased*
    -- Select One --123
22. Is this a WaterSense labeled Toilet?*
    -- Select One --YesNoI Don't Know

    Check WaterSense toilets on the EPA’s website (LINK).Only WaterSense toilets are eligible for the rebate.

24. New Toilet and/or Installation Cost*
25. Toilet Installation Date*
    Toilet Installation Date
26. Property Type*
    -- Select One --Single-FamilyMulti-FamilyCommercial
28. A copy of your purchase receipt and/or invoice for installation cost MUST accompany this form.*

    Please make sure the receipt number, vendor, date, amount, item, and quantity are all clearly visible.

30. By Checking Each Box, You Certify the Following:*

    1. I have purchased this toilet(s) on or after October 1st, 2024.
    2. This toilet(s) was installed and in the City of Charlottesville.
    3. I am a utility customer of the City of Charlottesville water utility (and my account is in good standing) or homeowner of a home in the City of Charlottesville.
    4. I am replacing a toilet that uses 1.6 gallons per flush or more.
    5. I am installing a new WaterSense labeled toilet.

    You must check ALL boxes to be considered eligible for this rebate.

31. Choose Method of Rebate Payment*
    -- Select One --Send a CheckCredit Utility Account

    Note: Checks can only be sent to the name listed under the utility account or the owner listed via the assessor database.

33. Electronic Signature*

    By adding your full name here, you agree that everything above is correct and submitted by you.

34. Today's Date*
    Today's Date
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

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