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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> ?rojecl Numher __ _ �City to Pr'ovide) <br /> r�iBd3E cOiiiNieiE �luQii 31UES Ui ii10 iuli7i <br /> Property Owner Section: <br /> r------ ----...--- --------- <br /> � ----------------- _ --- <br /> ! Property Owner Nam=: _��(� �(�y�rr� ; <br /> I _ <br /> , Inslallation Address ������� I <br /> � City: T�l`�1� State: __�-- p: "l�w� i <br /> � Maiiing Address (rl diHerenf): � <br /> � — <br /> i <br /> I City: Slate: Z�p:--- � <br /> � Email l ' 1�YY1e� � C.Uhldb� ,�_ Phone: (y]51 7�' 73_1� i <br /> j Total Cosl to Insiall Device (rrom conrractor invoice) S . 2 Y=!%S9 <br /> �--------�--------- . ._ � <br /> I, lhe property o��vner, requesl�o have Ihe City of EvereU Backwafer Pravention Oevice rebate chech <br /> for lhe installalion of the device al the a6ove referenced propehy address be made payable to. and <br /> senl to the vendor specified on the back of this (orm. By requeslinc� Ihe rebate check be made <br /> payable lo the vendor. 1 �gree lo Ihe (olloc✓ing: <br /> 7. i will nol receive a rebale check direcll, from the City of E��er�IL ` <br /> 2. Nssigniny payment of Ihe rebale to Iha vendor does not exe+npt me from Backwater � <br /> Prevenlion Device Rebate Program requirements � <br /> I <br /> ---.,._.--- -----._ ----- -- __ ---- - <br /> � I aulhorize tho release of my rebate to Ihe vendor lisled on Ihe back of ihis lorm pending � <br /> i <br /> I approval of the completed Backw�ler Prevenlion Devir,e rehate packet by Ihe Cily of Everell I <br /> i <br /> � <br /> � <br /> /; ' �'����-- �')')dv� —. �J���S -- I <br /> iSignature of Propedy Oevner p��� <br /> i • ' <br /> '_-.._____'._ "____ � <br />