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Lead Service Replacement

Rebate Program Application

APPLICANT AND SITE INFORMATION

This section below must be filled out by the Registered Owner(s) or by the Authorized Agent* for the Registered Owner(s) (herein referred to as the “Applicant”). The Applicant will be the primary point of contact for the application, however, any rebate amount will be issued to the Registered Owner.

Are you the registered owner of the subject property?

Yes

First Name

Last Name

Phone Number

Email Address

Address of Subject Property (Number and Street)

Postal Code

Applicant Mailing Address (if different than above)

City

Postal Code

Property Roll Number

Please upload the City Portion of the Lead Service Replacement Rebate Application.

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I confirm that a City staff member has filled out the City Portion of the rebate application.

Yes

Please upload the Contractor Portion of the Lead Service Replacement Rebate Application.

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Please upload the Contractor's Invoice.

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Please upload a completed the required Direct Deposit for Vendors Form.

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