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� . i <br /> � Back�Nater Prevention Device� <br /> ���� Re�bate Program <br /> � For intemal Use: Pro;ect Numher <br /> Ver�clor Pa�yment aption Form <br /> Please cotnplete both sides�of the Form <br /> Property Owner Section (please print): <br /> ---- --- ---- - ------ -- --- -- <br /> i <br /> ' --�1�11 r'.�=�'__---�_O_N�r�L-_ I <br /> •Property O�vner Nanie <br /> __3_J�-----�c2���e���� ,���r ��r�> a-- <br /> . �roperty A�s:��1 �( �;1� l ' / State :z,p I <br /> -----�—+— -` < V � �' � <br /> Allernal� i�ia�iii g Address i�iry j Stale ; Zip � <br /> �_2 3 = 30�_ / 3 � 1 ' <br /> Phone Email I <br /> ---------- -- i <br /> I, the Prcperty 0��:�ner, request to have the Cily of [verett Qackvdater Prevenlion Device <br /> rebai�a cf�eck for the installation referenced al the Property Address be nade p,3yat�le <br /> tc�, and s��nt io, the Vendor. f3y requesting the i�icentive/rehate check be made payable <br /> tn the Vendor, I agree to the following: ' <br /> t. I will not receive a Back�vater Prevention Devic,e rehate check direcUy from the <br /> Cily oi EveretL <br /> 7 Assigniny payinent of thc Backm�ater �'revention Device rebate lo the Vendor <br /> dqes not exempt mc from f�ar,k�vater Prevenliaii �evir.e Rebate Program <br /> ieyuiremenls <br /> I autl'�orize lhc releasc o( my reb�ite to the Vendor Gsled un p�u�c lwo o( this form <br /> p�nding approval o( the completed Bachwater Prevef�lion Device rr.bnte �iackaqe by <br /> the City oi �verclt � <br /> --- --- -��-v,.:`�'�- o� ._��-�-- �/3�/!_s <br /> , <br /> Signa!ure o/Properfy O�•.'ner Da(e <br /> i <br /> P��C 1 n(2 <br /> Rovlsed 9r3/2U 14 � <br />