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%ia/�' Backwate� Prevention Device Rebate Program <br />�i'� ' ��'•• Vendor Payment Option Form <br />.� .�.. <br />\. <br />ProJect Number: _ fC�Y b ��) <br />Pledse complete both sides of the form <br />Property Owner 5ectian: <br />Property U+ner Name: �M • ����� _ � <br />InstaliationAddress: ���2�7 w����L_T � . ___ <br />�-� .,.,,/ '� ��� � •-) <br />CR9� ��LC S.E�=LT —. _ Slate Gl. •r4 . 2�: i f? .c �� � <br />Meihng Address (d AAra�nq: <br />CRy: „ _ SWte' 7_ip:- -- <br />Email:�'(�KPj���`�L�iGO.<C.%�2PN�ne'(�) �GS ��LF�% <br />� � � <br />Total Cost lo Install �ewce j/mm contra�fa mvoice) S��( ; <br />1,1ho property owner, request lo heve Ihe City of E��aretlBBck�vater Prevention Devi; e rebate check <br />for lhe insfallation o! ibe devlce at Iha atwve re(orencEd proparty :iddress be made payable to, and <br />seN to, the vendor sper,ificKl on the hack of ttiis Inrm 8y reryuesling the rebale che�:k he made <br />payable to lhe vendcr. I aqree to Uie mllo�vina. <br />i. 1 will no� recerve a�rbate check mractW from tlie Gity ot FveretL <br />2. Ass�gning paym�ni ef ihe �ehalc io tP�e •n:ndui de�s nol b�r.mpt r.re harn �e:�ar�:er <br />Prevention Cevice Rebale Frodrem requirem�nts. <br />I aulhonze fhe releace ut rt:y �obale ta Il,e venda listed on ihr, beck �t thls fnm� pending <br />approval of the c�cmpleted Bar.Mvater Preventlun Devicxi rebate peckal by Nie Cfty ot Evereri <br />Signaluro oi Property Umer <br />05����5 <br />Date <br />