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�^%^� Ba�;.kwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. (City tn Prov�de) <br />Please complete both sides of the fc,rm <br />Property Owner Section: <br />Property Owner Namc: V�� Gvn i�n � IAvl1 � p <br />3-'r- -_ - <br />Installation Address: `i�S (� v i ���� � n� __ J e._ <br />'_'T r — <br />Cily' � �Lf L� State' W�} Zip:_��7i'i � <br />�/� ,{ � <br />Mai�ing Address (il di!lerenQ: �'1� � V I fC� �1 h I��—�(Iv K+ <br />Ci1y: �'UQJI'� State. wk Zip: �g��0 � <br />1 <br />Email: �wa ��� $__�����LbJ . i.D��'1 �hone: (�� ��6'Ll3I ln _ <br />Tolal Cosl to Inslall Device (/rom contractor invoice): $��, �_ __ <br />I, the property owner, requesl to have the City of Everell �ackwater Prevention Device rebale check <br />for the installation of the device at ihe above referenced property address be rnade payable lo, and <br />sent to, ihe vendor specified on thu back of lhis form. By requesling the rebate check �e made <br />payablc to the vendor, I ac�ree to ihe follnwinc� <br />1 I wlll not receive a reb�+le r,l .�ck direclty from lhe City of Everell <br />2. Assigning paymenl ot the rebate to the vendor docs nol exempt me Irom Backwalcr <br />Prevenlicm Device Rehate Proc�ram requiremenls. <br />1 aulhoriic the relcase of rny rebale lo thc vendor listed on Ihe back of lhis form pending <br />approval of the r,ompleled dackwaler Prevenlion Devfce rebate packet by the City of [vere�l <br />� ��1 �� <br />SignaWre of Pwperly Owner Dale <br />