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Backwater Prevention Device <br />Property Owner Rebate Form <br />� <br />Backwater Prevention Device �iRebate Form <br />Print and return this form witli yourrebate packaye <br />Propeity Owner Name: __ L� i���c� �,p��-1-��1�` <br />� <br />Property address: , 1 i Z�� ��ua,��r fTr.'-� <br />City:. �ZT'�'�{"' State: � L�4"i� Zi � <br />_. P� �1SZ0!-Z4Z(� <br />Mailing address (if <br />City: � <br />Email address: <br />State: <br />� <br />Phone: <br />J <br />2ip: <br />Cost to install Backwater Prevention Device: S_ ��� •� <br />Rebate Package Checklist <br />P'ease check that you have completed and included the folloe�ing ifems in your <br />submrssion. /tems indicated as (CONTRACTORJ will be provided to you by yo�r <br />conlractor. <br />�The completed Backwater Prevention Devrce Rebate �orm (lhis formJ <br />�i,'� Niap of the property with location of inslalled Backwater Prevention Device <br />jCONTRACTOR] <br />[� A copy of the completed Baclnvater Prevention Device Final Installation Checklist <br />�[CON'fRACTOR] <br />[JJ The itemized invoice showing husiness name, address, license number and d�=tailed <br />cosls of installation and materials. [CONTRACTOR]. Note: No rehate wil! exceed the <br />fotal cost of the installafion o(the backwater p�evenlion device work. <br />�!1 Vendor Payment Option Form signed by both the.property owner and contractor IF <br />you would like the C::y of [verett to pay ihe Contractor directly. Othena�ise, 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 />Certification) <br />Page t of 2 <br />Revised 09/0912D1�} <br />