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� Backwater Prevention Device Rebate Program <br /> Verdor Payment Option Form <br /> Pro�eU Numbec _ _____. . (City to ProviAe) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> � Property Owner Name. _ � ����2Q,� _��.L� <br /> i -- - <br /> ilInstallation Address �Z�._�E��_�_r(�{T .____.__ _ _ <br /> I Ci�y �-_------- State' �---Zip:�20� <br /> Madmg AAdress(il diflerenf)� _____. ___ <br /> City ------ — - State -- Z�p' -------- <br /> Email: __ Phone ( )_ <br /> Total Cost to Install Device (Irom confractor invoice): $__ _ _ __ ___. _ _ __ <br /> ' -- --- __ _----- __ --- —.__ ----_ __ — <br /> I, the propeAy owner, request to have lhe City ol Everell Backwater PrevenLon Device rebate check <br /> tor Ihe mslallalion ol Ihe device at Ihe above relerenced property address be made payable to, anA <br /> senl to,lhe vendor specil�ed on Ihe back ol lh�s (orm By reques�mg �he reb�te r.heck be maAe <br /> payable to lhe vendor, I .iyree to the lollowing: <br /> 1 I will not rer.ewe a rebate cher.k d�•Ar,tly trom the City�f [veretl <br /> 2 �ssigning payment ot tl�e rebale to Ihe vendor dor.s not exempt me from Backwater <br /> Prevention Device Rebale Program reyutremenis. <br /> I aulhori;c Ihe rr.lcase of my rebate to lhe vendor lisled on ihe back of Ihis form pendin,y <br /> approval ol Ihe completed Back�valer Preventiun Dewr.e rebate packel by Ihe Cdy of Everelt <br /> ����.�=��=is���L i-- � (5 _ . . _ <br /> Signature ot Property Owner Date <br />