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. i <br /> Backwaxer Prevention Device � <br /> Rebate Program <br /> For inlemal Use: Ptojeci Number; ___ <br /> Vendar Payment Option Form .,-. ' <br /> Please r.omplete hoth sides of tho forrn j <br /> Property Owner Section {please print): <br /> I`---i' ----- —�------------- ---- -- ---- ------ <br /> � � l--�-v �z_; �i�-e�� <br /> � l",�t_1�.=�------ - <br /> F'roperty Owner Name �f---- -- -- -----�-- — -- <br /> / 1 1 /�C <br /> ��U �..=1 �(�_a. (I C: � Y. �Il'��.Q. n�.�� L/ 0�..��F'� I <br /> _ — — =UL_.—�:.--�---�—=—--` -- <br /> ! Property AddiesS c�ty st2te zi�� . . <br /> � <br /> i�lfurnate A9ailing Add�c�ss---��-Ciry`---- -State -------Zip —�-- <br /> I L 2'i - ? �� � .. C� ��� ')�� � <br /> � --�----------- ------- ----- �. <br /> Phone Email <br /> L the Prr�perty O��-ner, reyu�st to havr, ihe City of [verelt Backwater Prevention Device <br /> rebate chr�ck for the installaUon reteren�,e�l at the Properly Address he made payab�e <br /> to, and sent to, the V�ndor. l�y requestiny the incentivehebate check be made payable <br /> to the Vendor, I agree to the tollowing <br /> 1. I will nol receive a Backwato-.r Preventio� Device rebate check directly from the <br /> City of EverFit <br /> 2. Assigning paymenl of the E�ackwutur Preve�tion Device rebate to lho Vendor <br /> does nol exempt me frcm liackwater f'r��v��ntion Qevice Rebate: Program <br /> requiremenis. <br /> I aulhorize the release ot my «�bate to the Vendor listed on page two of this form <br /> pendiny appioval ot the complr.ted 13ar.kv,�ater F�r�vc�ntion Device rebate package by <br /> thr. City nf 6veretl ' <br /> � <br /> . � <br /> , . <br /> C k� -- --- _ �._ _ .�:_/�'_ � c� ^__ <br /> Signature nf Property Uwner Dafe <br /> Pagc 1 n(7 <br /> Revisi�d 9/3/201�: �. . <br />