2019 LAWN & GARDEN EQUIPMENT REBATE Name _________________________________________ Street ________________________________________ City/State/Zip___________________________________ Phone ________________________________________ Indicate up to two of the following you are applying for: $25 rebate for purchase of “clean” lawn mower (electric or push-reel mower) $25 rebate for recycling gas lawn mower (gas mower must be properly drained of oil/gas before recycling) Rebate Form $25 rebate for full season of “clean” lawn care service. $25 rebate for purchase of other qualifying “clean” (electric or battery-powered) lawn and garden equipment (please specify type of equipment) leaf blower string trimmer edger hedge trimmer chain/pole saw cultivator/tiller Affidavit Restrictions on Public Benefits Pursuant to C.R.S. section 24-76.5-103(4)(b) I _____________________________________, swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one of the following): I am a United States citizen I am not a U.S. citizen but am lawfully present in the United States pursuant to Federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States when asked as well as submission of a secure and verifiable document. I may also be required to provide proof of lawful presence. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. By signing this form, I certify that I purchased and/or recycled the lawn care equipment or service as stated above at the address indicated on the sales receipt. Printed Name ________________________________________ Signature ___________________________________________ Date _______________________________________________ STEP 1 Complete and sign affidavit. STEP 2 Complete rebate form and attach receipt. STEP 3 Obtain stamp on recycling rebate voucher if recycling a gas powered lawn mower (on back). STEP 4 Place completed form in envelope and mail to: 2019 Lawn & Garden Equipment Rebate Program Environmental Services PO Box 580 Fort Collins CO 80522-0580 FOR MORE INFORMATION 970-221-6600 or fcgov.com/lawnmower Rebates are issued on a first-come, first-served basis until funds are depleted. Other restrictions apply. Auxiliary aids and services are available for persons with disabilities. V/TDD: 711 Rules and Instructions 1. Rebates available to Fort Collins residents only. One rebate application per resident per year. 2. Rebates apply to qualifying equipment with a purchase price of $99 each or more. 3. Qualifying equipment includes electric or reel lawn mowers, electric or battery-powered string trimmers, hedge trimmers, edgers, chain saws, pole saws, cultivators, and tillers. 4. Recycling rebate is available ONLY for gas-powered lawn mowers. 5. Rebates are limited to $50 maximum per applicant 6. Purchases must be made during the rebate period (May 1 through July 31) and the rebate form must be received by August 2, 2019 to qualify. 7. Online purchases are not eligible. YOU MUST BE A FORT COLLINS RESIDENT TO APPLY. ONE REBATE APPLICATION PER RESIDENT PER YEAR. Attach purchase receipt here.