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i <br /> � <br /> � <br /> � Backwater Prevention Device Rebate Pragram ' <br /> Vendor Payment Option Form ; <br /> � <br /> Projed Number. (City fo Provide) � <br /> Please comptete both sides of the form <br /> Property Owner Section: ! <br /> Iproperty�tivr,cr Name: /I'7�iI� ����S '��l��� � <br /> Installation AAdress•.___����_ l�l Gi����/!(C � <br /> j Ciry: /��GI% _State: �_Zlp: 7 �2�� , <br /> MnIIIngAddress(lldlNerenQ• �Z�� fy�/l H� <br /> CiIY' �Yc.�6!I Slo�e: ��✓A Zip: / 8 �'�� � <br /> Email: l.� !,/� ri��/f 'G o�E . LO/Yl Phone: (4Z� �6/ ?33S <br /> �' , <br /> Tolal Cost lo Instell vice ((rom conVacforinvoico); 5 <br /> i <br /> I,lhe properly owner, requesl to have Ihe Cdy o1[verott f3ackwater PrevonUon Devico rebate check � <br /> for lhe instaliation ol ihe devicc a� Ihe above referenced property f�ddrr.ss hc mede pnyub�r,to,and ' <br /> sent lo,the vendor specifir.d on Ihe back of lhic form. Hy requcsting Ihc rr.Ua�c chr.r.k be made <br /> paya6le to Ihe vendor, I ayrec to the follov+ing: � <br /> 1. I will not receive a iel�ale check dlreclly from Uir.City of[vcietl � <br /> 2. Assigninc� payment ol Ihe rebate lo Inr.vendor does not exempl me from Back�vater <br /> f'revr.nlion Device Rebale Program requiremen�s. � <br /> I aulhori�e the release ol my rebate lo Ihe vendor hsled on Ihe back ot Ihis fonn pendiny � <br /> approval of lhe completed 9uckvealer Prevenlion Device rcUate par.ket by Ihe Cily of Evereft <br /> C���� .o , s ; <br /> SignaWre of Propeiiy Owner Datr, i <br /> i <br /> i <br /> � <br />