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� Backwater Prevention Device Reb�te Program <br />Vendor Payment Option Fnrm <br />Project Nvinber: <br />(City fo Provitle) <br />Please complete both sides of the form <br />Property Owner Section: <br />Properly Owner Name � <br />Inslallalion Address: � �',�.. �� <br />� i <br />�>I... �:� 'i�ci.,; <br />T <br />. '�_� .... Jl <br />Cil},; � - _ ::.;7._ Siale: '� Zip�. '�� ��'�- � <br />Nailing Address (rldilferenf): 1 ? ,• -' -� � '�� '� � <br />Cily. �. :1, .. ,.1, Slate: � `` <br />Email: ,..,_. ....i._., _ , r>- , ..�:� ...� -. <br />Total Cost to Insfall Device (from contracforinvoice): � <br />Zip: ����� : '1 . . <br />Phone� (�-�.,�_� ���, . : � �� <br />I, Ihe property owner, requesl to have Ihe City of Everell 6ackwaler Prevention Device rebate check <br />lor Ihe inslallation of Ihe devi�e at Ihe above relerenced propeny address be made paya6le to, and <br />senl lo, the vendor specified on Ihe back o( Ihis form. By requestiny Ihe rebale r,heck be made <br />payable Io the ventlor, I agree lo the followiny: <br />1. I will no� receive a rebale r,heck direcUy Irom Ihe Cily of Everell. <br />2. �ssiqning paymenl of the «:bate lo the vendor dors nul exempt me from Bar,k�vater <br />Prevention Devicc Rebatc Program requirements. <br />I aulhorize Ihc relcase of my rebate to Ihe vendor lisled on Uic back o( Ihis fmm pending <br />approval ol the compleled Bar,kwaler Prevenlion Device rebate paCY.r.t by Ihe Cily of f_verr.11 <br />_ . __ <br />-.._ '•"c,f.. � I..�� .. ��.11.i � ; <br />�—."" <br />Siqnalure of Property Owner Da�e <br />