Laserfiche WebLink
� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Praject Number __ ___ (City fo Provide) <br />Please complete both sides of the form <br />Property Owne, Section: <br />Property O�vner Name <br />tvlailing Address (il diHerenQ: C �f�}/�/� <br />City: Slale: Zip <br />Email: Phone: ( ) <br />Total Cosl to Ins�all Oevice ((�om confracfoi invoice): 5 L��/, <br />I, Ihe property ovmer, requesl lo have the Cily of [verell Dack�vater Prevention Device rebate check <br />for the installation of lhe device al the above referenced property address be made payabte to, and <br />sent to, Ihe vendor specified on the back ef ihis form. Dy requesUng the rebate check be made <br />payable lo the vendor, I agree to the following <br />I. I �vill not mceive a rebate check direclly from the City of Everclt. <br />2 Assigning payment of ihe rebate Ie Ihe v�ndor does not exempt me fwm Backwater <br />Prevention Uevice Rebate Program requiremenls. <br />1 aulhor¢e Ihe releasc of my rebale to thc vendor li;ted on Ihc back of lhis forrn pending <br />approval of ihe completed �ackwater Poevention Device rebale packet by the Cllq of [veretl <br />— -f--�-=`-� . <br />Signature of Prope y Owner Date <br />