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2. Review requirements and rain barrel rebate infomation.
   Water Conservation Rain Barrel Rebate Program

   You can get a $30 rebate for installing a rain barrel on your property in Charlottesville (up to 2 times).
3. 
5. First Name*
6. Last Name*
8. Service Address*
9. Service Address Zip Code*
11. Mailing Address*
    Put "Same" if your service address is the same as your mailing address.
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Water Account Number*
19. Email*
21. Number of Rain Barrels Purchased*
    -- Select One --12
22. Cost of Purchase*
23. Place of Purchase*
25. A copy of your rain barrel purchase receipt must accompany this form.*
    Please make sure the receipt number, vendor, date, amount, item, and quantity are all clearly visible.
26. Choose Housing Type*
    -- Select One --Single FamilyMulti-FamilyCommercial
28. By checking each box you certify the following: *

    1. I have purchased this rain barrel after April 20, 2009
    2. This rain barrel has been installed in the City of Charlottesville
    3. My Charlottesville water account is in good standing
    4. My receipt is for an actual rain barrel that was not homemade

    You must check ALL boxes to be considered eligible for this rebate.
29. Choose Method of Rebate Payment*
    -- Select One --Send a CheckCredit Utility Account

    Note: Checks can only be sent to the name listed under the utility account or the owner listed via the assessor database.
31. Name*
    Electronic Signature- By adding your name here you agree that everything above is correct and submitted by you.
32. Today's Date*
    Today's Date
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit Submit and Print

* indicates a required field