2. Free Toilet Pre-Qualification Form

   This form is for customers with single family residential properties only. If you have a commercial or multi-family property, please call 707-543-3985, or email [email protected].

   Santa Rosa Water customers may be eligible to receive up to two high-efficiency toilets, showerheads and faucet aerators for kitchen and bathroom installed by qualified plumbers -- at no cost. Funding for this project has been provided in full or in part from the California State Budget Act of 2022 and through an agreement with the State Department of Water Resources. To see more program details, visit www.srcity.org/Toilets.

   Eligible customers must:

   1. Be a Santa Rosa Water or sewer customer (pay your water or sewer bill to the City of Santa Rosa)
   2. Have a toilet(s) that flushes at 1.6 gallons per flush or more

   To be pre-qualified for the program, please fill out the information below.

4. Name of Water Account Holder*
6. Installation Address*
8. Name of Mobile Home Park or HOA (if applicable)
10. Phone Number*
11. Email *
13. Type of property*
    -- Select One --HouseCommercial (this form is for single family residential customers only)Multi-family (like apartments) (this form is for single family residential customers only)
15. A max of 2 toilets per residential site will be installed. How many toilets are you requesting?*
    -- Select One --OneTwo (maximum available)
19. Information about the first toilet you’d like replaced:
21. • Toilet location (such as guest bathroom or hall bathroom)*
23. Toilet brand *
25. Year toilet was installed (if known) *
27. Upload a photo of the information printed on the flat area behind the toilet seat’s hinge, where the bowl meets the tank *
28. Example
    How to Find the Flush Volume for a Toilet
30. • Upload a photo of the manufacturing date printed on either the bottom of the tank lid or the inside of the tank *
34. Information about the second toilet you’d like replaced, if applicable:
36. • Toilet location (such as guest bathroom or hall bathroom)
38. Toilet brand
40. Year toilet was installed (if known)
42. • Upload a photo of the information printed on the flat area behind the toilet seat’s hinge, where the bowl meets the tank
43. Example
    How to Find the Flush Volume for a Toilet
45. • Upload a photo of the manufacturing date printed on either the bottom of the tank lid or the inside of the tank
49. By submitting this form, I am certifying that:*

    1. I understand that my showerhead(s) and bathroom faucet aerator(s) will be replaced with high efficiency models in the same bathrooms where the toilets are replaced. If compatible, an aerator must be added to the kitchen faucet as well. Other water-saving fixtures are available if desired, but not required to be replaced. I also acknowledge the new toilet footprint may be different than the old toilet footprint which may result in exposed flooring.
51. Thank you for completing the Free Toilet Pre-Qualification Form. Due to the high volume of submissions, it may take up to 4 weeks for the Water Use Efficiency Team to complete the pre-qualification process.
Leave This Blank:


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

    This field is not part of the form submission.

55. Submit

* indicates a required field