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� <br />� <br />Backwater Prevention Device <br />Property awner Rebate Form <br />Backwa��ter Prevention I�evice Rebate Form <br />Print and retum fhis fonn with your rebate package <br />Propeity Owner Nanie <br />�,� <br />Propertyaddress: �3�'7 (� �r.�p. c � �� <br />�City1 E v�i'e� 5tate: i�� Zip; 2 0/ <br />,._.._ - <br />;Mailing address (iF different): <br />City:� State: ,7 Zip�i <br />Email•address: Samnh�lA/�JG/n���c�M Fiione:(�ZS�) 2I��70�G <br />, <br />oc <br />Cost to install Backwater Prevention Device: 5 2�G�. <br />Rebate Package Checklist <br />Please check fhat you have comp/eted and rncluded the (o/lowing items in your <br />sub,liission., Items indreated as (CONTRACTORJ �a�ip be provided to you by your <br />contractoc <br />�h� compleled Bac{^.vafer Prevention Device Rebafe Form (this form) <br />jJJ tvtap of the property with bcation of installed Backwaler Prevention Devir.e <br />[CONTRACTOR] <br />� A copy of the completed 8adavater Prevention Device Final Installation Checklist <br />[CONTRACITOft] <br />[�The item'ired invoice shovding business name, address, license number and detailed <br />costs of installation and materials. [CONTRACTOR]. Note: No rebate wil( exceed the <br />tota! cost of�the installatron of the baclnvater p�evention devrce �:�ork. <br />(�A Vendor Payment Option Fom� signed by hoth lhe property owner and contraclor IF <br />yoii v�ould like the Citv o( [verett lo pay lhe Contractor directly. OthenNise, the rebate <br />chec •will be made ou' and deli:�ered to you. <br />A completed and <br />ertification) <br />Revisr.d 09/D912014 <br />signed Form W-9 (Request for Taxpayer ldentification Number and <br />Pac�e 1 ot 2 <br />