Water Use Mitigation Program Rebate Form

Town of Danvers Appliance Rebate Application Form

Type of Rebate *

Water Account Number *

Name on Account *

First Last

Mailing Address *

Street Address Address Line 2 City

•If the rebate is for an apartment tenant or condo owner, the “Mailing Address” should be for the apartment owner or condo association. Unit information should be filled under “Installation Address”. These applications require both applicant and account holder cooperation, as the rebate check can only be made out to the account holder. If the appliance/fixture was purchased by the applicant, the account holder will need to reimburse the applicant directly.

Phone *

Email *

Resident Name (If different than account holder)

First Last

Installation Address (If different than account holder) - Must be a Danvers Residential Address

Street Address Address Line 2 City

•Rebates are available to Danvers Residents only. Applicants listed must be Account holders with all active accounts in good standing.

Resident Phone (if different than account holder)

Resident Email (if different than account holder)

Approximate Age of Existing Item, Fixture or Appliance

New Product Information *

Manufacturer	Model Number	Date of Purchase	Date of Installation

Toilet: How many gallons per flush? *

Please upload the following with your submission: (1) proof of purchase/receipt dated within 2 years of submission- must include model number; (2) product specifications with gallons per flush and (3) signed plumbers permit.

Clothes Washer: Most recent Consortium for Energy Efficiency (CEE) Tier # *

Please upload the following with your submission: (1) proof of purchase/receipt dated within 2 years of submission- must include model number and (2) product specifications with CEE Tier. Only one clothes washer rebate per household.

Showerhead: Gallons per minute *

Please upload the following with your submission: (1) proof of purchase/receipt dated within 2 years of submission- must include model number and (2) product specifications with gallons per minute.

Faucet: Gallons per minute *

Please upload the following with your submission: (1) proof of purchase/receipt dated within 2 years of submission- must include model number and (2) product specifications with gallons per minute.

Lawn Irrigation Rain Sensor: Is it wireless? *

Please upload the following with your submission: (1) proof of purchase/receipt dated within 2 years of submission- must include model number and (2) wireless product specifications.

Rain Barrel: # of gallons *

Please upload the following with your submission: (1) proof of purchase/receipt dated within 1 year of submission- must include model number and (2) product specifications showing number of gallons.

Signature

I have read, understand and agree to the Terms & Conditions below and have attached all required backup documentation requested above.

Required documentation *

Drop files here or

Residential Rebate Application Terms & Conditions:

Rebates are available to Danvers Residents only. Applicants listed must be Account holders with all active accounts in good standing. If account is not active or in good standing, rebate will not be processed. Rebate application will not be processed until application with required documentation is received. Incomplete applications will be returned. Please call 978-777-0001 x3011 for guidance.
If the rebate is for an apartment tenant or condo owner, the “Account Information” should be for the apartment owner or condo association. Unit information should be filled under “Installation Address”. These applications require both applicant and account holder cooperation, as the rebate check can only be made out to the account holder. If the appliance/fixture was purchased by the applicant, the account holder will need to reimburse the applicant directly.
Application requires: the proof of purchase with a clear line item displaying the product purchased with a model # in the form of the sales receipt, all required backup documentation for the specific appliance/fixture and a completed and signed Rebate Application.
The rebate program is on a first-come, first-served basis and is effective until the funding is exhausted or the program is discontinued.
New construction projects (any construction after January 2008) or home additions do not qualify for rebates since all usage in new construction or additions is considered an additional draw on Danvers’ water reserves. Rebates are for remodeling only.
Appliance/fixture must be replacing an existing appliance/fixture. Old appliances/fixtures cannot be reused by applicant or other Danvers residents. Appliances/fixtures must be installed at the account location. Danvers reserves the right to inspect the installation on premises.
Applicant agrees and understands that Danvers does not guarantee that the installation of a high efficiency appliance will result in water savings, as site-specific water consumption varies.
Danvers does not warrant, endorse or assume liability for the quality, performance or safety of the contractor and/or retailer or wholesaler or performance of any appliance/fixture. Responsibility for product chosen is solely the applicant’s.
Individual rebates more than $600 may require the issuance of a 1099 Tax Form.

Documents and forms

Water Use Mitigation Program Rebate Form