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Backwater Prevention Device Rebate Program <br /> 144;e Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: \,a fan)IyTt' sst tC() A" &,,r3)Vti / <br /> Installation Address: I (,O \ iC �-(GA ( lJ <br /> City: State:WA Zip: 9 s20 1 <br /> Mailing Address(if different): VDU( CC SCC(CL, I r) <br /> City. 0^C.th0 1S C(Ylr s State:'-4J A Zip: 9 SaS2 <br /> Email: 0 1ZU ey PYA le. Phone:a0 3s---)C <br /> Total Cost to Install Device (from contractor invoice): $ � ? <br /> I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at the above referenced property address be made payable to, and <br /> sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will not receive a rebate check directly from the City of Everett. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my rebate to the vendor listed on the back of this form pending <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> Oft".\--PAN16,,, j l f a <br /> Signature of Property Owner Date <br />