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� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Fo�m <br />Project Number. (City (o Providc) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: p�U��F (�[�(�IQ_ �-Y,�T(� � UF H�-EK <br />Installatian Address:�L�'/Z�,(Ll.�_ vF <br />City:l�UEr�ET Slatc:_��Z�P: �r�o2!/� <br />lvtailiny Address (ildiHc�ent)� <br />City: S1ale: _ Zip: <br />Emai� `� �se�( r�u � C� Gm� rc- , c�om Phone� (��1) % SD �� <br />ya� ,,3�.� -lo m S <br />To��i Cost to Inslall Device ((rom contractor invoice): £ <br />I, ihe property owner, requesl lo have Ihe Cily of Everelt 8ackwater Prevent�on Levice rebale check <br />for the installalion of the device at the above referenced property address be made payable to, and <br />sent to, lhe vendor speci(ied an the back of lhis (orm. By requesling lhe rebate check be madc <br />payable te the vendor, I agree to the following: <br />1 I will not receive a rebate check directly fwm lhe Cily of Evcrelt. <br />? Assigniny payment ol Rie rebale to lhe vendor does not exempl me (rom Backwater <br />Prevention Device Rebale Proyram requiremen�s. <br />I aulhorize lhe rclease of my rebate to Ihe vendor listed on Ihe back of lhis form pending <br />approval of the completed Rackwater PreveMion Device rebale packet by thc Cily of [verell i <br />/ ��' l-V��— � _ t <br />-- - oc cS / � <br />Sign ure o( Property Owner Dale <br />