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i <br /> i <br /> I <br /> Backwater Prevention Device ! <br /> , <br /> E� rr Rebate Program i <br /> l <br /> , <br /> POr intcrnal Utic�. Ih�qcr.l Nund�cr� {1 <br /> -- I <br /> Vendor Payment Option Form ; <br /> ; <br /> Please complete both sides of thc tonn � <br /> i <br /> Property Owner Section (piease print): ; <br /> --- - - - --- - - - — _._ ___ _ -- -- — � <br /> � <br /> i, _ • � � <br /> �c i"e;4 �-!�I'/� � <br /> _ _---- - -�---- - - ----- i <br /> -- - - . ._ _ _ .. . <br /> Property O�vna Name � <br /> t ! z ��K9'���v�_..�',.— -�i.'r�'�'"-- - -�`�� �)- 9�'j`r'�� i <br /> ___ _ _ ---------_. . ; <br /> Properfy Address Cily SI>de Zip ; <br /> — ---- --�- ------- -- -- --- -- ------ — t <br /> All�rnale Ni,iilinq rlddress Cdy Slate Zip ' <br /> .,c L <br /> �!') �1��_)_1.��/__" __ __ ' _ ' , I <br /> . _. _ _ __ . __. .. ".___ _ "_"'_ i <br /> Phone [mail � <br /> �_ ----- -- — ----------. _ _ - -- - { <br /> i <br /> �, the Properry Owrer, request lo have the City ol [verelf Backwatei Prevention Device ! <br /> rebale check for lhe installa�ion re(crenced at Ihe Properly Address be made �r,iy��blr j <br /> to, and sent fo, Ui� Vendoi. 8y iequesting llir. inr,enlivcheb;dc i'heck br rnad� pny;ahlc � <br /> �o the Vendor, I agiec: lo the (olloriing. i <br /> i <br /> r <br /> 1 I will nol receive a C�ar.iewater Prevenlion Device rebate check direcUy (ruir thr: i <br /> City ol Fverctl <br /> '.J.. Assiyning payment of fhe [3ackwater Preven6on l�ewce rebale to the Vendor � <br /> does nct exempl me (iom llackv✓ater Prevention Device Rebai�a Prograni I <br /> reyuircmenls ; <br /> i <br /> � <br /> ! <br /> I authonze Ihc rcica;e of my reb.ilc lo Ihe Vendor listed on paye hvo of this foini j <br /> pending ap�nuv,il ol lhe complcled Backwafr,>� !'revenlion Devu:e �ebale �iack.ige by � <br /> �he Ciiy of �vurell / • <br /> ! <br /> --�-- - - — `I -- - --- _ I <br /> '----- � '�� 7 �e � . <br /> --- -- � _— � <br /> ,Si�nalure nf i'iopr.rfy Ownr.r ll.'do ` <br /> f <br /> 1 <br /> i <br /> ��,�i,� � �.12 <br /> R�•��c...,� •11.;iLp I�: i <br /> � <br /> i <br />