Form Center

2. First Name
3. Last Name
5. Account #
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Phone #
19. Year Home was built
20. # of bathrooms in house
21. # of people residing in home
22. Age of Toilet being replaced
24. Gallon per Flush of toilet being replaced:*
25. New toilet manufacturer
26. Model name / #
28. Gallons per Flush
29. Price paid for toilet excluding tax
30. Date of purchase
31. Date of installation
33. Installed by

    1. Homeowner
    2. Plumber
    3. Other ____________________________
34. How did you hear about this program

    1. City Representative
    2. Newspaper Article
    3. Web site
    4. Other ______________________________
36. How many toilet rebates have you received or applied for from the City of Cocoa
38. I have read and understand the toilet rebate policy requirements as stated in the attached instruction sheet. I understand that in order to receive the rebate, I must dispose of the toilet that was replaced so it cannot be reused. I also understand that an inspection of the installed toilet may be required prior to rebate approval. The original receipt, UPC bar code and the GPF 1.28 or lower wording from each box for the purchase of each toilet must be cut from the new toilet box and attached to this application. Incomplete rebates will be returned. (Keep a copy for your records)
40. Signature*
    By typing my name in this form, I affirm the accuracy of information provided on this application. I understand that this constitutes a legal signature and confirms that I agree to the above terms.
41. Date
43. Mail completed form and attachments to: Water Conservation Officer-Toilet Rebate Program, City of Cocoa Utilities Department 351Shearer Blvd., Cocoa, FL 32922. This form and required attachments must reach this office by 9/30/20 to be processed and considered for this FY 19-20.
47. City Use Only
    City Use Only Current App. # ___________ Prev. App. # ___________ Date Application received: _________________________________ Purchase price of new toilet (excluding tax) ______________________________________ Original Receipt, UPC bar code and GPF verbiage from the box attached: yes _______ no ________ Number of Rebates per this address __________________ Inspection Date: _________________ Inspector: _______________________________________
Leave This Blank:


48. Print Only

* indicates a required field