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Firestone Toilet Rebate Program
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The Town of Firestone would like to thank the Colorado Water Conservation Board for the grant the Town received to help make this program available to all Firestone residents.
How to Apply and Program Rules:
• Purchase and install a qualifying High-Efficiency Toilet. For a list of qualifying toilet please visit
. The models listed were chosen for their efficient use of water.
• The product must be purchased after April 1, 2010. Rebate application must be submitted in the same year the toilet was purchased. Example if you purchased your toilet on July 15, 2010, you must submit your rebate application by December 31, 2010.
• Purchased toilet must be for use at an address that receives water service from the Town of Firestone. Residents of other cities and/or customers of other water providers are not eligible. A Town of Firestone water account number is required.
• Rebates can be filed by property owners and renters. Contractors or anyone else working with a property that they do not own cannot apply for a rebate. The property owners or renters are responsible for installation.
• The Town reserves the right to inspect the installation of any appliance for which a rebate is provided.
• One of each type of rebate per household and one of each type of rebate per household within a five year period.
• The original copy of sales receipt must be attached to the application and include the date of purchase, price, brand name, model number and serial number. Please keep a copy of the receipt for your records or apply in person to keep your original.
• A photograph of the installed toilet is required. As well as a photograph of the replaced toilet broken after being removed is required.
• All blanks fields below need to be completed for application to be processed.
• Provide proof of US citizenship or legal status in the United Sates by providing a photocopy of one of listed forms of identification on the Affidavit of Lawful Presence form. Complete the Affidavit of Lawful Presence section of the application and attach a photocopy of identification.
• Rebate program availability will be on a first come first service basis.
• When application and all required documentation is received applicants will be required to complete a short survey on the rebate program in order to complete the application process. Applicants can either complete the survey online at
or by picking up a survey at Town Hall.
• Once all the above steps are completed the Town of Firestone will issue applicants rebate. Please allow up to six to eight weeks to receive rebate.
Water Account Number
Property Street Address
Purchase Date for Toilet (mm/dd/yy)
Installation Date for Toilet (mm/dd/yy)
Estimated Age of Toilet Being Replaced
Toilet Model Number
Toilet Serial Number
Number of Bathrooms in the Home
Number of People Living in the Home
One Form of Identification (Valid Colorado Drivers License, Valid Colorado ID, U.S. Military Card, U.S. Military Dependant's ID Card, U.S. Coast Guard Merchant Mariner Card, Native American Tribal Document)
Scan of Appliance Receipt of Purchase
Photo of Destroyed Toilet
Photo of Installed Toilet
AFFIDAVIT OF LAWFUL PRESENCE IN THE UNITED STATES
I swear or affirm under penalty of perjury under the laws of the State of Colorado that (select one):
I am a United States citizen, or
I am a Permanent Resident of the United States, or
I am lawfully present in the United States pursuant to Federal law
If I checked (2) or (3) above, I hereby authorize the Town of Firestone to verify such statement with the Department of Homeland Security using my alien registration number, which is:
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 agree my electronic submission of this form constitutes my signature affirming the above information is true and correct.
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