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BaCKWA�'ER PREVENTION PROGRAM <br />d INVOfCE �OST BREAKnCaWN <br />Please use this Invoice Cost Breakdown as a!emplate for invoices submitted as part of the Backwater <br />Przvention Devi�e rebate program. Either ihis form or your ov�n invoice torm with the follo�ving line items can <br />be submitted. This allows yo� to invoice your client according to your existing billing temolate uvhile allowing <br />ciry staH to identify ho�v costs eligible for the Backwater Prevention Device Rebate were accrued. <br />Only labor and maferials directly related to the installati�n and function of a backwater prevention <br />device are eligible (or City rebate and therefore should 6e included on the upper half of thfs form. <br />Additional costs rnay be added to bottom of the form. <br />5���;' � � � �� <br />Business Name: ��(�f >�r'� �+"n��-� �,�e License t�umber. �(' s' � <br />Business Mailing Address: <br />� <br />Phone: �Xo'•�IL> ".�Y!�� Email:(�ill�%1�� �/rl�/'iC' � �� 'c-[)/1�1 S'dNl;ar�Z�f: C°c� <br />Revised 9/03/2094 <br />