High-Efficiency Toilet Upgrade Application Step 1 of 9 - Qualifications 11% Step 1: QualificationsIn order to qualify for a high-efficiency toilet through our program, you must confirm that you meet all of the following criteria:* I am replacing a toilet at a residence that receives water from the city of Lafayette or Longmont.* I have NOT received a toilet through this program for the same residence before (Will be verified. Exceptions made on a case-by-case basis only.).* I am replacing a toilet that uses MORE than 1.28 gallons per flush.* I understand that I need to take multiple measurements to ensure the new toilet fits in my bathroom as detailed in this form.* I have read the refund policy here.* If you do not meet ALL of these qualifications, unfortunately you are not eligible for the 2019 Flush for the Future program. You may still purchase a Niagara Stealth toilet at a competitive retail price at Resource Central located at 6400 Arapahoe Road in Boulder. Step 2: Contact InformationName* First Last Email* Address Where the Toilet Will Be Installed* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Water Provider (will be verified)*--- SELECT ONE ---LongmontLafayetteIf you cannot select your water provider, toilets are sold out or temporarily unavailable in your area. If your water provider is not listed, this program is not currently offered in your area. DO NOT SELECT ANOTHER WATER PROVIDER. If your water provider is sold out, you may add yourself to our notification list, and we will contact you if more toilets become available in 2019. Water Account Number (as listed on your water bill)*We use this to verify your Water Provider. Phone*Email Updates Yes, I’d like to be added to the eNews mailing list where I can learn about how to put conservation into action in my own life and find out about other exciting conservation opportunities! Step 3: Survey Questions These survey questions have been included in order to provide your water provider and Resource Central with better information on the demographics of the participants in this program. Please answer the questions honestly. Resource Central guarantees that your responses will not be associated with your personal information, nor will they impact your eligibility for this program. Only anonymous, aggregated data summaries of your answer to these questions will be used in any reporting or assessment of the responses. Do you or any of the current occupants of your household directly pay a water bill for the water used within the household where the new toilet will be installed?*YesNoWhat is your total annual household income before taxes?*Household = All full-time residents. Please combine if applicable.Less than $25,000$25,000 to $49,999$50,000 to $99,999$100,000 to $149,999$150,000 to $249,999More than $250,000Prefer not to answerHow many full time year-round residents live in your household?*123456 or more Step 4: Gallons Per Flush (GPF)Examine your toilet to find a marking that indicates the Gallons Per Flush (GPF). Select the appropriate option below.* The program goal is to conserve water, so existing efficient toilets are not eligible for replacement. If you have a dual flush toilet, please take the average of the two flush volumes as your single GPF number. Your current toilet must use more than 1.28 gallons per flush to qualify. My toilet uses more than 1.28 GPF.I don't see any GPF markings on my toilet.My toilet uses 1.28 GPF or less.This toilet is already efficient, so it does not qualify for replacement through this program. We suggest replacing a different toilet in your home.If you cannot find a GPF marking, look for a manufacture date stamped inside the tank or on the bottom of the tank lid. If the toilet was manufactured before 2005, it almost certainly uses more than 1.28 GPF and qualifies for this program. If, however, the toilet was manufactured in 2005 or more recently, it may only use 1.28 GPF; please research the specified GPF for that model and year before proceeding. Step 5: Toilet ClearanceMeasure from the floor to any shelf or other obstruction above the tank of your current toilet as indicated by the green line. Select the appropriate option below.* The Niagara Stealth toilet features an elegant silver flush button on top of the tank. A minimum of 36 inches of vertical space is recommended to have enough room to comfortably reach the flush button. Note: This is a critical measurement to ensure the Niagara Stealth toilet will properly fit in your bathroom. You will not be eligible for a refund if the new toilet does not fit. Please refer to the refund policy here. No shelf/obstruction exists above my toilet.I have at least 36 inches of vertical space.I have less than 36 inches of vertical space.The Niagara Stealth toilet will likely not properly fit in this space. We suggest moving the obstruction or choosing another bathroom. Step 6: Rough-In Measurement & Toilet ShapePlease measure the bathroom rough-in to verify it is an appropriate size for the new toilet. (See the illustration for instruction on how to take this measurement.) Select the appropriate option below.* Note: This is a critical measurement to ensure the Niagara Stealth toilet will properly fit in your bathroom. You will not be eligible for a refund if the new toilet does not fit. Please refer to the refund policy here. The rough-in is 11.75 inches or greater.The rough-in is less than 11.75 inches.The rough-in will accommodate either a Round or Elongated toilet bowl. Please review the dimensions of each toilet below, and measure your bathroom carefully to ensure the toilet you choose fits. Select which you prefer.* You will not be eligible for a refund if the new toilet does not fit. Please refer to the refund policy here. Round Best in smaller bathrooms/spacesShorter and therefore better for shorter individualsConsidered more standard for a home toiletElongated Larger so requires more spaceTaller and therefore can be more comfortable for certain peopleADA compliantThe Niagara Stealth toilet won’t fit in this space. We suggest trying another bathroom. Step 7: Choose your Pick-Up EventPlease click Pick-Up for $85, then select the Pick-Up Event at which you choose to pick up your new toilet.*Pick-Up — $85.00 You must be available to pick up the new toilet during one of our designated Toilet Pick-Up Events at Resource Central (6400 Arapahoe Road in Boulder). Includes:Niagara Stealth Toilet, toilet seat and wax ringRecycling of your old toilet that uses MORE THAN 1.28 GALLONS PER FLUSH (gpf) during your Toilet Pick-Up Event at our 6400 Arapahoe Road location in Boulder-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------Toilet Pick-Up Events will be:*--- SELECT ---Thursday, December 12 from 2:00pm-4:30pm (This is our last event for this program. You must be able to come to this event in order to participate in the program.)If you are not available for any of these Toilet Pick-Up Events we will contact you when more dates become available. We are happy to answer any questions at 303-999-3824 or water@resourcecentral.org. Step 8: ReviewPlease review your order details below and proceed to the next page to enter your payment information. In order to qualify for a high efficiency toilet through our program, you have confirmed that you meet all of the following criteria: {High Efficiency Toilet Program Qualification Confirmation:63} Name: {Name (First):1.3} {Name (Last):1.6} Email: {Email:3}{Email Updates:6} Phone: {Phone:4} Address Where the Toilet Will Be Installed: {Address (Street Address):2.1}, {Address (Address Line 2):2.2} {Address (City):2.3}, {Address (State / Province):2.4} {Address (ZIP / Postal Code):2.5} Water Provider: {Community (will be verified):5} Do you or any of the current occupants of your household directly pay a water bill for the water used within the household where the new toilet will be installed?: {Do you or any of the current occupants of your household directly pay a water bill for the water used within the household where the new toilet will be installed?:67} What is your total annual household income before taxes? {What is your total annual household income before taxes?:68} How many full time year-round residents live in your household? {How many full time year-round residents live in your household?:69} Pick-Up Selection: {Do you want to pick up your new toilet or have it delivered to your home?:26} {Toilet Exchange Days will be::40} Toilet Measurements: {Measure Vertical Space:10} {Check Gallons Per Flush:44} {Measure Rough-in:12} Toilet Selection: {Qualify for Round or Elongated:13}* I have reviewed the information above and confirm that I entered all of this information accurately.* Step 9: PaymentPlease confirm the following:* I am purchasing this toilet to replace an existing inefficient toilet that uses more than 1.28 gallons per flush. I understand this is a requirement of this program.* I have read and understand the refund policy.* {pricing_fields}Address Where the Toilet Will Be Installed: {Address (Street Address):2.1} {Address (Address Line 2):2.2} {Address (City):2.3}, {Address (State / Province):2.4} {Address (ZIP / Postal Code):2.5} Is your billing address different?*Yes, I need to enter a different billing addressNo, my billing address is the sameBilling Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Credit Card* DiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name Please click the submit button only once to prevent processing errors.NameThis field is for validation purposes and should be left unchanged. 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