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�zckwater Prevenkian Device Rebate Program <br />V�ndor Payment Option Form <br />Nro�ec:l Nu�raer _ (Cfty to ProvideJ <br />F�Ipase complete both sides of the form <br />Property Owner 5ection: <br />Propony Owncr Nomo: <br />Installa!�vnAdd�ess �� � ��d �%9 � <br />�i�Y- G4�r�-1�" --Stete J ���� Ztp. ����d I <br />hfloiiinp Rddress (i!dlfletenq: <br />C�ty: , . _ Staic: � __ Z�p• � <br />Eme�i �'ii�ll�G� �'� d'J�7f.'CtJ�`�')_'4�' _Fhone�L�i �d��% (` <br />Tatal Cosl m Insiatl Dovic.o {Iram ccrntrector �niroice) $ ft. ��-—' <br />I. 1he property avaner, rnquesl ln h�ve Ihc Cliy af Fverelt Back�va(cr Pratiu�iion �evice rohalo rhr:ck <br />for ihe installslion �f lho ti�vi� at Ihe �above re(etenced piuvcrty �iddress tsr: mqde payub�e ro, and <br />senllo, thp ventlor specdled on Ihe hack ai ttiu (nrm. py mqueslmg the rr.t��ie check be made <br />pnyabl� lo Ihe vendor, t aj�rye I�� Ihn Inllowing: <br />1 1 wlll nnt re[eiyr, t� rebalp theck dueclly trbm 11tr� Cdy oI Evernil <br />7�l�s�gnirtg payment uf thn rebafe In the vend�r dees nol er:empt ma from da�kwater <br />Prrv�n!ion L7Avir.c+ Rehale Pm3r�m tequiratm�t!ts <br />I nuthorlTn the rr_�nnr;a oi my reb�ta to ltii� vend�lr ��s1�tl �n the 6nck ot thfs t�rm �ending <br />apprnvai 6f ihe camplNLd Ela�kv�at�r Prevr.nlion LlevicC �ebaie pa�knt hq Iho Cdg vI Ever�tt <br />C fC[ /'� � ��R� y � <br />Y <br />Siflnsl�tt4. Properly Ov�ner Oate <br />) ;olo <br />