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. i <br /> � Bac water Prevention Device <br /> E� � Pro erty Owner Rebate Form <br /> � Backwater Preve��tion Device Rebate Form <br /> Print and return this form with Xour rebate package <br /> P�Harty.Owne�N e: Rv/e�/ 2�'`�� <br /> Property�dd s Z`�!'7 I ('�On,Z � <br /> �City:—��r ,� Stete: , -�� _Zip: � �ZO 1 _ <br /> I <br /> Mailing.address;(ifdifferent): j <br /> .r--- -- -• - <br /> cCity~'`" � State: Zip; <br /> Email'ad'dress: ; Phone: �12-5 ►7.3Z-�9(p <br /> Cost to install F3ackwater Pre,vention Device: $ 2_ .'r�b�� f3�-� <br /> � <br /> I <br /> Rebate Package CheckllYt <br /> P/ease check that you have co�npleted and included the following items in your <br /> submisslon. Items indicated asj(CONTRACTO4J wlll be provided fo you by your <br /> confractoG <br /> he completed Backwater P4evenUon Oevice Rebate Form (this formJ <br /> ap of the property with loc�tion of installed Backwater Prevention Device <br /> [CO�GTORj <br /> A copy of the compleled Ba�kwater Prevenfion Device Flnal Installatlon Cher.klist <br /> [CONTRACTOR] ' <br /> I <br /> e itemized invoice showi 'g business name, eddress, Iicense number and detailed <br /> costs of installation and materi�ls. [CONTRACTOR]. Note: No rebate will exceed the <br /> total cosf of fhe installafion of the 6ackwaler prevention device work. <br /> A Vendor Payment Option Fjorm signed by both the property owner and contractor IF <br /> you would like the Cily of Everatl to pay the Contractor directly. Otherwise, the rebate <br /> check will,l e made out and delipered to you. <br /> compieted and signed For�m W-9 (Requesl for Taxpayer ldentiflcatfon Number and <br /> ertification) <br /> ' Page 1 0(2 <br /> Revised 09109/2014 � <br />