REQUEST FOR SUBSIDY

Date: ______________

Mail Or Fax This Form To:

Water Meters Subsidy Fund
Post Office Box 990
Corte Madera, California 94976
Phone: (415) 461-0410
Fax: (415) 461-0412

The California Water Meters Subsidy Fund provides a subsidy to California Public Water Districts that purchase non-lead meters from ABB Water Meters, Inc., Hersery Meters, Inc. or Master Meter, Inc. Subsidies are available for qualifying purchased made at any time after May 31, 2000 for residential water meters in sizes 3/4” or smaller. This form must be used when requesting a subsidy under this program, along with a purchase order that includes the quantity of meters purchased and their prices.

Mail subsidy payment to:

DISTRICT NAME: ________________________________________________________________

ADDRESS: _____________________________________________________________________

CITY: ____________________ STATE:____________________ ZIP:__________

TELEPHONE #: (_____)____________________ FAX #: (_____ )____________________

EMAIL ADDRESS:__________________________________________________________

CONTACT PERSON:__________________________________________________________

YOU MUST ATTACH A COPY OF YOUR PURCHASE ORDER

Invoice #: ____________________ Date: ____________________

Quantity Purchased of each size: _________________________________________________

TOTAL SUBSIDY REQUESTED: $ _____________________________