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� Backwater Prevention Device <br />Property �Wn�r Rebate Form <br />Backviiater Prevention Device Rebate Form <br />Print and retum this form with your rebate package <br />Property Owner Name: v"`�� <br />�'�n M � T �*dE., <br />Property address: ��� <br />Stdte: W�— <br />Zip: �l O <br />c�ri: �-� <br />Mailing address (if different):_.�- <br />�--- <br />State: <br />Z�p: <br />City: �. �-L '�S-I- �oy l�l <br />��/'sB-t'�./���'J�����hone:(�i�7 )�� <br />Email addr,ess: %�. .� 2 ya� 5 q <br />Cost to install Backwater Prevention Device: S <br />Rebate Package Checklist <br />Please check that you have completed and included the followin, items in your <br />submission: Items indicated as jCONTRAC70R] will be prov%�ed to you by your <br />contractor. <br />,, he completed Backwater Prevention Device Rebate Form (l'nis form) <br />�ap of the property with location of installed Backw.:ter Prevention Device <br />[CONTRACTOR] �', <br />�copy of the completed Backwater Prevention Device Final Install: tron Checklist <br />[CONTRACTOR] <br />�ie itemized invoice showing business name, address, license number and detailed <br />total ost �fthetinstallation of the backwate�r Prev�eRtion de�vice work.e W��� exceed the <br />[�Vendor Payment Option Form signed by both the property owner and contractor IF <br />you would be made out and delive ed to youContractor directly. Otherwise, the rebate <br />check w II <br />A completed and s�gned Form W-9 (Request for Taxpayer ldentification Number and <br />Certification) Page 1 of 2 <br />Revised 09109I2014 <br />