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BACKWATER PREVEIVTION PROGRAM <br />� INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a tempiate for invoices submitfed as part of the Backwater <br />Prevention Device rebate prograrn. Either this form or your own invoice form with lhe fullowing line items can <br />be submitted. This allows you to invoice your client according to your exist�ng billing template while alloiving <br />city staff to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only labor and materials directly relateo to the installation and function of a backwater prevenfion <br />device are eligible forCiry re6ate and therefore should be included on fhe upperhalf oi thls tn►m. <br />Additional costs may be added to bottom of the fortn. <br />������ � � �� �c1 <br />Business Name:Q 1� _� ��'�7�L'LSLi e se Number: __�S,7�a��� <br />BusinessMailingAddress:vfG�c% l-C-�-/�I�v� C.11�-• j.�,/[%7('{� r.r��, ���x <br />City State Zip <br />Phone:,��`.�/C�-',�yY!�� Email:�'� �)n Nr���zn, � "� �C.bc',-��'!:i'r_r7Yl <br />Revisad 9/03/2014 <br />