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TOILET REPLACEMENT PROGRAM - RESIDENTIAL REBATE

Application forms can be dropped off at the City's Client Service Centres located at:
Ottawa City Hall (110 Laurier Ave. W), Kanata (580 Terry Fox Dr.), Orléans (255 Centrum
Blvd.), Ben Franklin Place (101 Centrepointe Dr.), Kinburn (5670 Carp Rd.), Metcalfe
(8243 Victoria St.), and North Gower (2155 Roger Stevens Dr.).
Or mailed to: 951 Clyde Avenue, Ottawa, ON K1Z 5A6 - Attention: Be WaterWise
Applicant Information
Last Name First Name
Address OTTAWA, ON Postal Code
Phone Number (home) Phone Number (business)
Water Billing Account Number Tax Roll Number 0614

(if applicable)
Toilet Installed by Original Toilet Flush Volume Number of Bathrooms Condominium Fees
Do-it-yourself 13L 1 bathroom not applicable
Plumber/Contractor 20L 2 bathrooms water included
Unknown 3 or more bathrooms water not included
City Approved Toilet (see Terms and Conditions)

Toilet Manufacturer / Make Model or Model Number
Receipt Date Installation Date Age of House Required Attachments:

Years Before photo
dd / mm / yy dd / mm / yy After photo
Original receipt
Reason for the purchase (check all applicable)
bathroom renovation leaking or broken toilet new owner
rebate program conservation other
Information Release - Water Billing Information

All residents applying to participate in the City's Toilet Replacement Program agree to provide the City with access to water billing
information for the participating residence for the purposes of determining program effectiveness. Any information included in any
publicly released analysis, study or report regarding program effectiveness will not include any personal or identifying information.
I have read, understand, and agree to the terms and conditions of the City of Ottawa's Toilet Replacement Program. I
acknowledge that all of the information provided above is true and correct.
Signature of Applicant
dd / mm / yy
Personal Information on this form, including the applicant's Water Billing Account Number, is required for the purposes of the City's Toilet Replacement
Program, which is part of the City's Water Efficiency Plan as approved by City Council. Such personal information will be used for the purposes of
administration and management of the Program. Questions regarding this collection may be addressed to: the Project Manager, Environmental Programs,
Infrastructure Services and Community Sustainability, City of Ottawa, 951 Clyde Avenue, Ottawa, ON K1Z 5A6.
Disclaimer and Release

The City makes no representation or warranty, express or implied, relating to any fixture or the availability, competence, workmanship or financial status of any
installer, and by submitting this Application Form each Applicant will be taken to have fully and unreservedly released the City with respect to any claims for
costs and liabilities in connection with the preparation for and/or the replacement of any fixture and the installation and/or use of any fixture for the purposes of
participating in the Toilet Replacement Program including, without restrictions, all costs and all liabilities for any and all loss or damage, whether direct, special,
consequential, indirect or of any other nature.
For Internal Use ONLY
Service Request Number 20 _ _ - Staff Initials
Received / / Approved Denied

dd/mm/yy rationale
TOILET REPLACEMENT PROGRAM - RESIDENTIAL REBATE
Terms and Conditions
Steps to receive the Toilet Replacement Program - Residential Rebate

Step 1 - Review the full Terms and Conditions.
Step 2 - Select a toilet from the City's approved toilet list (available on-line or at your nearest Client Service Centre).
Step 3 - Purchase the selected toilet on or after September 21, 2007.
Step 4 - Before removal of the existing toilet, take a "before" photo.
Step 5 - Install or hire someone to install the new toilet.
Step 6 - After completing the toilet installation, take an "after" photo.
Step 7 - Submit the completed application form, including tax roll number, original toilet receipt, and "before" and "after" photos.
Step 8 - At the City's discretion, allow City staff or designate to verify installation and flush volume of the new toilet.
Eligible Houses
To be eligible for consideration under the Toilet Replacement Program - Residential Rebate (Program), a house must:
- Be located in the City of Ottawa (City)
- Be a single detached, semi-detached or privately owned row house, condominium apartment or townhouse
- Be built prior to 1996
- Have at least one (1) older toilet with a flush volume of greater than 6L that is to be replaced
Conditions of Payment
Payment of a rebate under the Program is conditional on:
- Completed installation of the toilet listed on the application form
- Proof of Ownership (tax roll number) of the property where the toilet is being installed
- Proof of Installation through the provision of "before" and "after" photos
Selection of Participants
- The City will provide a maximum of two rebates per municipal address.
- The Program does not apply to toilets installed as a result of new construction or additions.
- The Program is only available to residents replacing high flow fixtures (greater than 6L per flush) with a low flow
fixture (6L or less per flush). Only the toilets on the City's four APPROVED TOILET LISTINGS will be considered
for a rebate application.
Application Deadline
- The City reserves the right to extend or terminate the Program based on available funds.
- Rebates will be issued on a first-come basis based on the City's date and time stamp regarding receipt of applications.
Applicant's Responsibility
Each Applicant must assume all financial and all other responsibility for:
- Selecting an installer/plumber as required
- Selecting from the approved City of Ottawa listing (available on-line or at your nearest Client Service Centre) and
installing the 6L or less toilet
- Any preparatory or repair plumbing work that is required for the proper installation of the 6L or less toilet
- Proper disposal of the old toilet
- Ensuring that the proper building/plumbing permit as applicable is obtained
Provision of Information and Access to the City

Each approved applicant must provide the City with;
- Access to water billing information
- If requested by the City, within a period of 6 months from the date of receipt by the City of this Application Form,
access to verify that the flush volume of the installed toilet is less than 6L per flush

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TOILET REPLACEMENT PROGRAM - RESIDENTIAL REBATE

Last Name First Name

Address OTTAWA, ON Postal Code

Phone Number (home) Phone Number (business)

Water Billing Account Number Tax Roll Number 0614

City Approved Toilet (see Terms and Conditions)

Receipt Date Installation Date Age of House Required Attachments:

Information Release - Water Billing Information

Disclaimer and Release

Received / / Approved Denied

Steps to receive the Toilet Replacement Program - Residential Rebate

Provision of Information and Access to the City

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