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� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: <br />(City fo Provide) <br />Please complete botn sides of the form <br />Property Owner Section: <br />Property Owner Name: �_�= '=" '`�" �'I w�a-+�-`�� aN <br />Inslallation Address: vl � � �� �� _ __ <br />City: �� �k.�'�' Stete: _j�___ Zip:___ � 3-O <br />MailingAddress(i(dif/erent): ���� - ��`� ,'� R�^-�'-f� <br />Cily: Jl'� �-01�"� �`' StatFs: w� z�P: q`Sa9 c� <br />Email: � 1 � ]'`�°° � �7°-�,m . �^'l' Phone: (�6) �� -A %i-3 <br />Tolal Cost to Install Device (Irom confracfor invoice): $ _ <br />I, Ihe property owner, requesl lo hava lhe Cily of Everell Backwater Prevr.ntion Device rebatc check <br />(or the installation of the device at the above referenced property address be made payable to, and <br />sent to, lhe vendor specifieA on the back oi Ihis form. By requesting the rE�6ate check be made <br />payable lo the vendor, I agree to the (ollowing: <br />1, i will not receive a rebate check directly (rom the City n( Fverelt. <br />2. Assigning payment of lhe rebate to the vendor doos not exempt me from Backwater <br />Prevention Devicc Rebate Prograrn requirements. <br />I aulhonze Ihe rclease of my rebale lo the vendor listed on the back of Ihis form pending <br />approval of the compleled Backwater Prevention Device rebate packet by Ihe City o( Everell <br />�� <br />� <br />Signalure of Property Owner <br />� i ------ <br />a,1��,� <br />�,�e <br />