Water Rebate Form

2. Rebates are for Danvers' residents only with active accounts in good standing.

4. Type of Rebate*
   -- Select One --ToiletClothes WasherShowerheadFaucetLawn Irrigation Rain SensorRain Barrel
6. Water Account Number*
8. First Name*

   Name on Account

9. Last Name*
13. Mailing Address*
15. Address Line 2
17. 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.

18. State
19. Zip Code
21. Phone
22. Email
26. First Name

    Resident Name (if Different Than Account Holder)

27. Last Name
31. Street Address

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

33. Address Line 2
35. City

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

36. State
37. Zip Code
39. Resident Phone (if different than account holder)
40. Resident Email (if different than account holder)
42. Approximate Age of Existing Item, Fixture or Appliance
46. New Product Information
48. Manufacturer*
49. Model Number*
50. Date of Purchase*
51. Date of Installation*
53. Toilet: How many gallons per flush? *
55. Required Documentation*

    Please upload the following with your submission:

    1. Proof of purchase/receipt dated within 1 year of submission- must include model number
    2. Product specifications with gallons per flush
    3. Signed plumbers permit.
57. 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, ext. 3011 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 Number 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.
59. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
61. Electronic Signature
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field