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i <br /> I <br /> Backwater Prevention Device Rebate Program <br /> 47, <br /> Vendor Payment Option Form <br /> i <br /> i <br /> Project Number: (City to Provide) I <br /> I <br /> 3 <br /> I <br /> I <br /> Please complete both sides of the form <br /> i <br /> Property Owner Section: 1 <br /> F <br /> f <br /> i <br /> Property Owner Name: 2•0 4/ ��jy�r ,--..- i <br /> 1 <br /> Installation Address: / /d o 4.1_ 0,e.‘44/ g,e <br /> City: {4dYt�T_ State: 11.1--- Zip: 9PZ0 1 <br /> Mailing Address(if different): Q 'S.-0 d - t,,_.) <br /> City: Pvi 4 It.-1 a State: F/`-in" Zip: 9e ,"1-3— I <br /> Email:leen n y . 67e/4„ °i'^" /1.o+14,1,1 Phone: (WZI 317 <br /> i <br /> Total Cost to Install Device (from contractor invoice):$ i <br /> I <br /> i <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 2 <br /> payable to the vendor, I agree to the following: <br /> F <br /> 1. I will not receive a rebate check directly from the City of Everett. • <br /> 1 <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> 1 <br /> 3 <br /> E <br /> I authorize the release of my rebate to the vendor listed on the back of this form pending I <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> 3 <br /> `s <br /> s <br /> 66.--, a/,',./J-- , <br /> Signatre of Property Owner Date } <br /> i <br /> i <br /> i <br /> i <br /> i <br /> { <br />