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2. Upon submission of this form, you will receive an e-mail with further instructions in 1-2 business days.
4. First Name on Water Account*
6. Last Name on Water Account*
8. Water Account Number*

   This is found on your water bill. If you need help with this number, please call the DPW at 781-270-1670. If you are in an apartment complex, please enter "1."

10. Water Service Address*

    House and Street Number Only

12. Do you own or rent this property?*

    1. Own
    2. Rent
14. Is your service location the same as your billing address?*
    -- Select One --YesNo
16. If different, please enter your billing address
18. Name of person in household who qualifies for this rebate*
20. Phone Number*
22. Email Address*
24. Disclaimer:

    By signing this document, I am certifying under the pains and penalties of perjury that either I, or a member of my household covered by the above-referenced account is a member of a sensitive subgroup:

    • Pregnant
    • Nursing
    • Infant under 1 years of age
    • Compromised immune system 

    I certify that the information I am providing is true and accurate. I acknowledge that I will be received a credit on my Burlington water bill only until the Burlington DPW deems this rebate as being no longer applicable. I understand and acknowledge that participation in the Burlington DPW Water Bottle Rebate Program is voluntary, does not guarantee that I will not be exposed to PFAS from an sources, and is not required by the Burlington DPW by law or regulation. If I should no longer need bottled water, I agree to contact the Burlington DPW immediately to remove me from the Bottled Water Rebate Program.

26. Please type first and last name as certification of above*
28. Today's Date*
    Today's Date
Leave This Blank:


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

    This field is not part of the form submission.

32. Submit

* indicates a required field