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I <br /> � <br /> � <br /> I <br /> � Backwater Prevention Device Rebate Program � <br /> Ve�dor Payment Option Form ; <br /> Project Number _ (Cih�fo Prowdr,) � <br /> � <br /> 1 <br /> Please complete both sides of the form � <br /> Property Owner Section: � <br /> -----.. ----- - - ------- <br /> (' j <br /> Property Owner Name�. �C1L.(1 i�l?. (l l �1 � Il!�-<'( LU� <br /> Instellalion Address�. �,� >�� '� ��P/�tlA � )�- <br /> Giry ��-1�'�rf;t�r 5tate ��,[�_2ip 1 ��r) � ' <br /> -- I <br /> Mailing Address(i/dillerenQ _ �� <br /> Ciry: Stale: 2ip: _ <br /> Email � <�URI�F'f' I � � �'� ��o� InA1 � �DIYl Phone (��75) 3)% D1��� <br /> Total Cost to Inslall Device(Imm cnnfracMr imoice): 3 <br /> I, the properly owner, request lo have the Cily o1 Fveretf Backwater Prevenlion Device rebate check ; <br /> (or Ihe inslallalion of the device al the above referenced proporty address he matle payable to, and <br /> sent lo, Ihe vendor speciAed on Ihe back of Ihis form. By requesling the rebate check be made ; <br /> payable lo Ihe vendor, I agree to the following: <br /> 1 1 will not receive a rebale check directly Irom the City o1 EvereU <br /> 2. Assigninp payment o1 the rebate to Ihe vendor does nol ezempt me hom Dackwaler ' <br /> Prevention Device Rebate Program requirements <br /> I aulhorrze the release ol my rebate to the vendnr Gsted on the bnck of this lorm pending <br /> approvat of Ihe compleled (3ackwaler Prevention Device rebale par.ket by Ihe C�ty ol Fveretl � <br /> ! <br /> i <br /> ��t. , i.�F � 1 ,• • — 0 ''� ' � � I <br /> �� <br /> Signature ol P�operty Owner Datc• � <br /> ---._ --. __. . _ . _ . .. __ � -� -- - - - - � <br /> � <br /> i <br />