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��Backwater Preventior� Device Rebate Program <br />E,, Vendor Payment Option Form <br />Projeci Number� __ (C�ty to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />PropcAy Owner Narc <br />�nslal�.:�ion Address- <br />CiIY �11_�� -- <br />A9ailing Address (i� ddferent). �' �' <br />City: � State ZiP <br />Email: ���.��✓� 1..I+� •� Phonc: N�) ,[tx ' _t�t1F— <br />Total Cosi lo Inslall Device (l�om contmcfor invaice)�. 5��,�ii 1� a l{ <br />I, Ihe preperty owner, request to ��ave the City of Fvr.rclt 6ackwater Prevenli0n Oevice reCnte cheAk <br />for thc installa6on ol lhe davice at Ihe above referenced property address be mado payabic tc, ...,.. <br />se�t lo, the vendor specifetl on Ibe back uf this torm. By reqursting the rebate check be made <br />payabte to lhe �endor, I ag�ee to the follo�•,ing� <br />1. I will n0t rBCeive 3 rCbate cheC4. Oirectly Irom the City o` FverBn <br />2. Assigning paymenl o� Ihe rebale lo the vendcr dces nol exempl me from Backwale; <br />Prevenllon Devlr.e Rebate Program requirements. <br />I aulhonzc Ihe release of my iebale lo tlie vendor IlsteA on the back ot this (orm panding <br />approval of the completeA Dackwater Prevention Device rebate packel by Ihe Ci1y ol r_veietl <br />�r --f" -- -�/1�i �s - <br />Si3naturr. of Property Oivner Date <br />