Free Toilets for Low-Income Homeowners — 4 of 6

Based on your answers, you may be able to receive a free toilet.
We will now ask you for contact information, proof of eligibility, and other basic information.

Please enter your first and last name

First name

Middle name

Last name

Please enter your current address.

Address

Apartment, suite, etc. (optional)

City

State

ZIP Code

Please enter your 10 digit phone number.

(US and Canada only)

Enter phone number

Email address

Please enter your email address

Date of birth

Please enter your date of birth in the format mm/dd/yyyy

Are you a homeowner or a renter?

I own my home

I am a renter

Alternate contact

Is there someone else we may contact in the case that we cannot reach you to schedule installation?

Yes

No

Personal information entered on this form is subject to Washington Public Records Act, and may be subject to disclosure to a third-party requestor. At the City of Seattle, we are committed to protecting your privacy and will ensure that any disclosures are done according to law. To learn more about how this information is managed please see our Privacy Statement: http://www.seattle.gov/tech/initiatives/privacy

Free Toilets for Low-Income Homeowners4 of 6