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� BACFCWA7�R PREVEIVTION PROGRAiVI <br />� INVOIrE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a t�=.mplate for invoices submitted as part of the Backwater <br />Prevention Device rebate program. Either this form or your o�vn invoice form with the tolloeving line items can <br />be submit:ed. This allodvs you to invoice your clienl according to your existing billing template while allo�ving <br />city stafl to identify how costs eligible for the Back�vater Prevention Device Rebate were accrued. <br />Only labor and materials direcfly related to fhe installation and function ef a badn�aterprevention <br />device are eligible (or City rebate and theref'ore sfioald be included on lhe upper half of this form. <br />Additional costs may be added to hoftom of the (omi. <br />� � V..C� <br />BusinessName:�n1Pr-ir_��i� � C. �,..,�C��.SLi e seNumber. (>������� _ <br />Business fvlailing Address: of(�uv (JGc� (cpi t�l-- �����'��! �•� �� � -� ��Ws ���— <br />City St2te Zip <br />Phone:�-'(p-�Q-�_a'�-- EmaiL�:_l1�l��nnl�r�������.eii�l s'.irC�-r2'(: C' > 7 <br />Revised 9/03/2014 <br />