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BACKVI�ATER PREVENTION PROGRAM <br />INVOICE COST BREAKDOWN <br />Please use this Invoice Cost Breakdown as a template for invoices submitted as part of the Back�vater <br />Prevention Device rebate program. Either this form or your own invoice form wiih the foliowing line items can <br />be submitted. This allows you to invoice your dient according to your existing billing template while allowing <br />city staH to identify how costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only laborand materials directly related to the installation and funetion of a backwater pievention <br />device are eligiDle for Ciry rebate and therefore should be included o�: !he upper hal,f lof this form. � <br />Additional cosfs may 6e added to bottom of the form. Z.-` ZQ ��� �(^� h <br />SL�cc� ;�� ���t7 <br />Business Name;A�lyri i�>>�+ �� r_'' ;� 2 License Number. __(:Jj��i�'�`7O <br />- _ ., .. <br />Business Mailing Address: Oflt�uc �%T r 1� �� �� �"" ' � i- '= gtate Zi <br />.r A L�._ u _ t• _/�� �. _ . ?/ <br />Z`I�`�`-� <br />Revised 9/03/2014 <br />