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� Back�roater Prevention Device Rebate Program <br />Vendor Payment �ption Form <br />?�O�er� IJUn1hPr: <br />(C;ry� ro Pravlr!el <br />�IP.aS@ l;UI11�lIEi�9 iJOiil SfiIBS Oi t�1Q iOlTii <br />Property Owner Section; <br />-----• -- ---� <br />Properry Ovmer �'ame: _ �. ' Ldl� <br />Installatlon Address: _ � � %�- � �+����y���_�� � ` <br />City: —_ _ �j �/ �– --- Slale' .. W/1 _ Zip: L u � � --- <br />T <br />Malling Adtlress (iJdiNerenO: ---- ^%�j�+.7 �•aJS.CyY,l� � <br />c��y: _;o a-Fk� s�,��: �^//� z�r�-- % S�� � s <br />. <br />Email: ---- Ov ����r. a�-4. tp�,. F� e. i�-�K7 _f��}d '`1 S$ <br />Total Cosl to Inslail Devlce (Irom contracfor Invoice): S ?`� ��• �� <br />I, Ihe property ownor, requesl lo have fhr City of [veroll Backwater Prevenlion Devlte rebate check <br />(or the InstallaUon of the devico ol Iho above refvrenced property address be made paYablo lo, and <br />sent lo, the vandoi specifled on the bach of Ihls lorrn By requestinc� Ihe reLale check be mode <br />pa•�able lo the vendor, I apree to Iho following: <br />1. 1 will nol recoive a cebafo check directly (rom ihe City uf [ver211. <br />?. �ssignln,y pnyment o( lhe rebale to Iho vendor dous not c:xempt mo from Backwaler <br />ProvenUon Devlco Reoale Program �equiromeNs. <br />I aulhorize lhe rele�sa ol my n:bate lo Ihe vendor lisled on Ihu bnck o( thls form pondiny <br />appioval of Ihe completed Backwater p�eventlon Devico rebalo Uar.kr.t by the City ol [vereu <br />� <br />-----C�_—_� <br />Slgnature of Property Owner <br />�-�r �l <br />Onlc <br />