2. Utility Account #*
3. Name of Account Holder*
5. Email Address
6. Phone Number*
8. Address of Conservation Upgrades*
9. Year House was Built
11. Mailing Address if Different Than Above
13. Purchase Information
15. List purchase date and retail store for each qualifying device. Limit of five rebates per utility account.
17. Item #1*
18. # Purchased*
20. Purchase Date*
    Purchase Date
21. Retail Store Where Purchased*
22. Upload Receipt*
24. Item #2
25. # Purchased
27. Purchase Date
    Purchase Date
28. Retail Store Where Purchased
29. Upload Receipt
31. Item #3
32. # Purchased
34. Purchase Date
    Purchase Date
35. Retail Store Where Purchased
36. Upload Receipt
38. Item #4
39. # Purchased
41. Purchase Date
    Purchase Date
42. Retail Store Where Purchased
43. Upload Receipt
45. Item #5
46. # Purchased
48. Purchase Date
    Purchase Date
49. Retail Store Where Purchased
50. Upload Receipt
52. Rebate Terms

    I have read, understand, and agree to the following:

    1. Rebate is available for any Derby Utility customer. Account must be active at the address of installation. The name on the utility account must match the name on this rebate application. New construction is not eligible for rebates.
    2. Devices must be purchased between Jan. 1, 2023 and Dec. 31, 2023. Rebate applications must be postmarked no later than 90 days after the purchase of the qualified products.
    3. Sales receipt of the device(s) must be provided with the application or it will be denied. Applicants must reapply if they were denied for not providing a sales receipt.
    4. The installed water conservation device(s) must meet the water-efficient specifications found at www.savewichitawater.com.
    5. In accepting this rebate, I understand that qualifying items are selected on the basis of water efficiency only. The City of Derby does not endorse specific brands, products, or dealers; nor does it guarantee the materials, workmanship, performance, or durability of the qualifying items.
    6. I understand that no rebate will exceed the purchase price of the item(s). Sales tax and labor charges will not be rebated. The rebate will be in the form of a credit to my City of Derby utility account. The rebate may take up to eight weeks for approval. A maximum of five items will be eligible for rebates per utility account.
    7. Installation of any rebated device, appliance or fixture is my sole responsibility, as is the determination of the adequacy and compatibility of the existing plumbing system and compliance with the City of Derby plumbing code. I understand that the City of Derby assumes no responsibility or liability for any damage that may occur to my property as a result of my participation in this program. I also understand that the City of Derby cannot guarantee that the installation of rebated fixtures or measures will result in lower utility costs due to circumstances beyond its control.
    8. Old appliances and/or toilets must be disposed of in an approved manner that will prevent any further use or reuse of the old device.
    9. I understand that the City of Derby reserves the right to amend and/or discontinue this program without notice. Any future programs will be adjusted to current standards.

    I certify that the information on this application is true and correct to the best of my knowledge. I also certify that I have read the Rebate Terms above and agree to comply with these conditions and terms.

54. Do you agree to the rebate terms?

    1. Yes
56. Signature (type your name)*
57. Date
    Date
Leave This Blank:


59. 1. Receive an email copy of this form.
60. Email address

    This field is not part of the form submission.

61. Submit

* indicates a required field