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Step One

First Name
Last Name
Account #
Location of Rain Barrel
Address2
City
State
Zip
Mailing address (if different)
Address2
City
State
Zip
Phone #
Year home was built:
Does your home have gutters
How many downspouts are installed
Do you have an in ground sprinkler system
What year was it installed
How many zones:
What type of water do you use for irrigation
1. Well
2. Reclaimed Water
3. Potable Water
Did you purchase or make your rain barrel (s) _
If purchased, indicate where
How many rain barrels were installed
Gallon capacity of each barrel:
What is the manufacture of the rain barrel:
How did you hear about this program?
1. City Representative
2. Newspaper Article
1. Web Site
2. Other
If Other-
How many rain barrel rebates have you applied for from the City of Cocoa
I have read and understand the rain barrel rebate policy requirements as stated in the attached instruction sheet. I understand that in order to receive the rebate, I must make/purchase and install the rain barrel in the current FY. I am responsible for calling and setting up an inspection for the installed rain barrel prior to rebate approval. The original receipt and UPC bar code from each box/item for the purchase of each rain barrel must be attached to this application. Incomplete applications will be returned. (Keep a copy for your records)
Signature*
By typing my name in this form, I affirm the accuracy of information provided on this application. I understand that this constitutes a legal signature and confirms that I agree to the above terms.
Date
The original receipt and UPC bar code from each box/item for the purchase of each rain barrel must be attached to this application. Incomplete applications will be returned.
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Step Two

Mail completed form to: Water Conservation Officer-Rain Barrel Rebate Program, City of Cocoa Utilities Department, 351 Shearer Blvd., Cocoa, FL 32922 (form, attachments and Inspection must be submitted and completed by 9/26/2020).
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Step Three

City Use Only
1 st Rebate # _________ 2nd Rebate # __________ Date application received: _______________ Purchase price: _____________ Lot size: __________________ House sq. ft. _________________ Green space: _________________ Original receipt and UPC bar code from the box included: yes _______ no ________ Number of rebates at this address __________________ Inspection date: _________________ Inspector: _________________________________

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

This field is not part of the form submission.
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Rain Barrel Rebate Application

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