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, i <br /> � ; <br /> '_ i <br /> Backwater Prev�ntion Device � <br /> Rebate Pr,ogram ; <br /> � � <br /> � <br /> , <br /> For internal Use: !'roject Nwnber. _ _ _ _ ! <br /> i <br /> Vendor Payment Option Form� <br /> Please complete both sides of the form � <br /> Property Owner Section (please print): I � <br /> � <br /> - ---- <br /> �- - -- --- - -��- - — - { --- ' <br /> � <br /> � <br /> , ------- <br /> '-.=-=���LL-�:._�� � � -�_.�li:➢�),c' %_, I � <br /> Proporty.OwnerNpme i --- -_ � <br /> i ��� -- <br /> I <br /> =��=<u/1F1�_�-�r�I� " l�-r� ,�,!�;:_ l������,--� � <br /> Pro�erty.Address ! � �� � <br /> � ,, City State Zi� r <br /> -- -�ji--. _.. ___ --C--- --- � i <br /> Altemate'Mailing-Address ty State <br /> 7_ip <br /> � <br /> F'hon� � _-- _ -- -,_— -_--- �� -- — --�,�. � <br /> �„_`,r ,y�'� ,_ t'-,'i, Gmail i <br /> - ---- <br /> - - ..--- = - -. .,_. � <br /> -�--- — _ _-- — -- <br /> f <br /> I, thc properly Owner, request to have the City o( [ve�ett Backwater Prevention Device � <br /> rebate check for the installat�r,n referenr.ed at Ihe Property Address be made payable � <br /> to, antl sent �o, ihe Vendor. By requestin� the incenlivA/rebate check be rnade payable � <br /> Io the Vendor, I aqree to the fallowmg: ; <br /> i I will riot ieceive a BackK��iter Nrevention Devic4 rr.bate check directly from Ihe f <br /> Cily oi FvereU. <br /> 2 Assigning p,iyrnent of lhe Backw��ler Prevenfior� Uevlce reha�e to the V�:ndor ' <br /> does not exempt mia irom Bar.kwater f'ievenlion f)evice Rc:bate Prograrn � <br /> requirements � <br /> I aullinrii�> ihe rr.lPasn of rny rnbatc lo tlie Vendor hsted on page two of fhis form <br /> pr�n.liny uppruval of Ihe r.onipleted Rackw�lcr P��:ventiun I)evice rebate par,kage by i <br /> ihe Clty of Evci�tl � <br /> , / I � <br /> 1 � �,� _ <br /> -1'-�7:i: -/� L:f� � -�_l����%��_ I �_ =-- - ' <br /> ig��aluie nl Pinpe�ty (�wner; �, Date i <br /> i <br /> � ' <br /> � <br /> I I <br /> Revised9/3J?014 i Pac�r, 1 of 2 <br /> , I <br />