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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. (Cily lo Pr�vide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vner Name: ��S i i r� lf�� � f�� � <br />Inslallation Address: 5� �� l a �3� ��jc._ <br />City:._�.�J' F �' i� Stale: t� A Zip� �1 Q� 3 <br />Maiting Address (if differentJ: <br />Cily: <br />Emaii: <br />Stato: <br />Zip: <br />Phone: ( <br />Total Cost to Install Device ((rom contractorinvoice): �__� ��% �� J� <br />I, the propeity owner, request lo have the City of Evereft I3ackwater Prevention Device rebate check <br />tor the inslaliation of the device at the above refetenced property address be made payable to, and <br />senl lo, tho v�ndnr specified on Ihe back of ihis form. By requesting Ihe rebate check be made <br />payable to the vendor, I agree to the following: <br />I wi�l noi receive a rebate check direclty (rom the City of Everell. <br />2. Assigning payment of lhc rebale lo Ihe vondor does not exempt me (rom Backwater <br />Prevenlion Devicc Rebale Program requiremeMs. <br />I aulhonze lhc release o( my re6ale lo lho vcndor lisled on the hack o( this (orm pending <br />approvai of Ihe completed [iackwatet Prevention Device rebate packet by thc Ciry of Gverel[ <br />�-- <br />� � <br />Signature of Property nwn r � , <br />�- 3-��� <br />Dale <br />