K-6 - Stormwater Best Management Practice - Rain Barrel

Stormwater Best Management Practice (BMP) Reimbursement Program Application Form Applicant/Property Owner: Address: ____________________________ City, State & Zip Code: ____________________________ Email Address: _____________________ Phone Number: ________________________________ Proposed Best Management Practice (BMP): ☐ Rain Barrel The below documents are required to be attached to this application: ☐ Cost summary ☐ Anticipated project completion date Estimated Cost of Project: ____________________________________________________________ Reimbursement Amount Requested: ____________________________________________________ • 50% of cost of a rain barrel with a maximum of $75 Program Details - See program description, instructions & conditions on next page: • Reimbursement will be made after the project is completed & the receipt has been submitted • Submit application & the the receipt to the following mailing or email address: City of Tiffin (Attention: Brianna Wilkerson) 300 Railroad St Tiffin, IA 52340 [email protected] ACKNOWLEDGEMENT By signing this application, the applicant agrees that all information provided in this application and the accompanying documents are true and accurate and further agrees to the follow the conditions of this program. The City of Tiffin can have access to my property and photograph the installed best management practice(s). Applicant Signature: ____________________________ Date: ____________________________ This section to be completed by the City Public Works Staff Approval: _______________________________________________________ Date Approved: ____________________________ Amount Approved: ____________________________