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� Backwater Prevention Device Rebate Prograrr+ <br />Vendor Payment Option For�ni <br />Project Number: _ ` (City to Provide) <br />Please complete both sides of the form <br />Property Owner 5ection: <br />Property Owner Name: �%A/h fS1�'������J_- �'i_tiii�' � Fl���� <br />Inslallation Address: �7 � '1 �/�"t�/�/�4• .Av/. <br />City: �(/�i�si� Slale: _GiA. Zip:���d/ <br />Mailiny Address (i( di(lerenQ: _ <br />City: <br />Email: <br />SWte: <br />Zip: <br />Phore: ( ) <br />UO <br />Total Cost ro Install Device (from conhacfor invoicef: $_ 2� ��10- <br />1, Ihe property owner, requesl to have the City of [verell Backwaler Prevr.n�ion Device rebate check <br />for the installalion of the device al Bie above referenced property address be made payable to, and <br />sent to, lhe vendor speci(ied on the back of this form. 6y requesling the rebate check be made <br />payable to �he vendor, I agree lo the following: <br />1. I will not receive a rebale check duecUy from �he Cily of Everell. <br />2. Assiyning payment of Ihe rebale to lhe vendor does nol ex�anp; me from Backwaler <br />Prevenlion Device Rebalc Proyram requiremenis. <br />I aulhorizc Ihe release of my rebale lo thc vendor lisled on Ihe back ol this fonn pending <br />approval of thr. compleled Backwaler Prevention.Uevice rebate packel by lhe Ciry oF [verell <br />Signature of Proper�y Owner <br />�-Io-/S <br />Date <br />