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�� <br />� <br />Backwater Prevention Device <br />Property Owner Rebate Form <br />Backwater Prevention Device Rebate Form <br />Print and reiurn fhrs form with your rebate package <br />Property Owner Name: <br />Property addre'ss <br />�� 1 Ct�/i <br />9 . ) <br />City: r �10 State: �/"� <br />Mailing address (if different): <br />City: <br />Email address: <br />State: <br />Phone: <br />Cost to install Backwater Prevention Device: $�(.Ob <br />Zip: <br />Zip: <br />Rebate Package Checklist <br />Please check that you have complefed and included the following items rn your <br />submission. I(ems indicated as (CONTRACTORJ will be provided to you by your <br />contractor. <br />� The completed Backwater Provenlion Device Rebate Form (this form) <br />J$J Map of tl�e property with location of installed Backwater Prevention Device <br />[CONTRACTOR] <br />� A copy of the completed Backwater Prevention Device Flnal Mstallation Checklist <br />[CONTRACTOR] <br />� The itemized invoice showing 6usiness name, address, license number and detailed <br />costs ot installation and materials. [CONTRACTOR]. Note: No rebate will exceed the <br />to�al cost of the installafion of the backwater prevention device work. <br />� A Vendor Payment Option Forrr signed by both the property owner and contractor IF <br />you wouid like the City of Everett to pay the Contractor directly. Otherwise, the rebate <br />check will be made out and delivered to you. <br />(� A completed and signed Form W-9 (Request for Taxpayer ldentification Number and <br />CeRiFication) <br />Page 1 of 2 <br />Revised 09109/2014 <br />