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2. Rebate Program

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6. First Name*
7. Last Name*
9. Address*
11. 1.*

    Do you currently receive a water bill from either Rubidoux Community Services District or Jurupa Community Services District?

    1. No.
    2. Yes.
12. 2(b)

    Congratulations, if you currently receive your water bill you do not need to complete this application, you will receive a rebate from your water agency.

14. 2(a)*

    Are you a resident of Jurupa Valley?

    1. Yes
    2. No
15. 2(b

    This program is only for residents of Jurupa Valley.

17. 3(a)

    Please check the box below if applicable:
    Due to COVID-19 I have had difficulty paying utility bills

    1. Yes
    2. No
18. 3(b)

    American Rescue Plan Act Funds must be used to help households recover from the Negative Economic impacts of COVID-19.  If you experienced any hardships due to COVID-19 you should check "Yes" and continue. No records will be requested.

20. 4(a)

    Are you able to submit a utility bill with your name and current adress on it?  Utility Bills must be current  (within 6 weeks of submittal).

    1. Yes
    2. No
21. 4(b)

    In order to verify that you live in the City of Jurupa Valley a utility bill is required to be uploaded  as part of the application

23. Phone Number*
25. Email Address*
29. Document Upload

    Please upload a supporting document .... Name on utility bill must match applicant

    text text

31. Browse your computer for document*

    Accepted file formats: PDF, JPG, GIF, PNG

33. Browse your computer for document

    Accepted file formats: PDF, JPG, GIF, PNG

37. Acknowledgement and Authorization

    By submitting this form, I understand that this rebate opportunity is being provided by the City of Jurupa Valley Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum.Lorem ipsum dolor sit amet, consectetur adipiscing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur. Excepteur sint occaecat cupidatat non proident, sunt in culpa qui officia deserunt mollit anim id est laborum.

    1. I authorize this application to be submitted
39. Full Name Authorization*

    Provide the full name of the person that is authorizing the submission of this form. This will serve as your electronic signature.

40. Date of Authorized Submittal*
    Date of Authorized Submittal

    Provide the date for the authorization/electronic signature.

44. If you have any questions please call so and so at (951) 332-6464 ext XXX

    Or email: helpfulperson@jurupavalley.org

Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field