SmartFlush Voucher Program Application
Water Account Number: __________________________ Check One: o Own o Rent
If renter, a Landlord Consent Form is required (download at www.savefortworthwater.org)
Address ______________________________________________________ Zip _____________
Home ( ) _____________ Day Phone ( ) ______________ Cell ( ) _______________
Toilets Requested - Available in white only (Place the number in the blank, maximum of 2)
Regular ______ Handicap ____ If you request a handicap toilet, doctor’s verification is required.
Number of bathrooms _____ Number of Showers _____ Year Home Built _______
Voucher Agreement - Please Read, Sign and Date
• I understand that I can receive up to two free toilets, if my home has two bathrooms. All
information will be verified using Tarrant Appraisal District records.
• I understand that if I rent, I must submit a signed Landlord Consent Form with this application.
• I understand that I am responsible for toilet installation within 30 days of pick up. The City of
Fort Worth recommends using a qualified plumber.
• After 30 days, I consent to an inspection upon notification by a Water Department representative.
• I acknowledge that the City of Fort Worth is not responsible for the condition of the plumbing
on my side of the meter now or in the future.
• I understand that failure to comply/install may require that toilets be returned or payment pro-
Applicant Signature ____________________________________ Date _______________
Forward completed application to SmartFlush Voucher Program via:
• Email: Scan and email application to firstname.lastname@example.org;
• Fax: 817.392.8735; or
• Mail: SmartFlush Voucher Program, 1130 Fournier Street, Fort Worth, TX 76102