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Backwate� Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Pro�ecl Nurnber _ _ _ _ (Gty fo P�nvidr.) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> _ . _ _ -- <br /> �— - - _ ^ �j �I <br /> , Prope�ty Owner Name � O .tj/ 1"'d `• � �� ^:�_ _ — -_ -- I <br /> IInstallation llddress 2 3 � �( v � �'�'� �( C � _ _ — I <br /> � Cdy _�v _�_e th _ State -��'�---- Zip--��ZC �---- I <br /> Mading Address (d ddlerenfl - - __._- ---.-----__ — -_ --- ----- �I <br /> I <br /> Cdy — -- -- - — State — --- -Z�P—_ — --- I <br /> . I Ema�l _� 9rtek�(�� �„ �� , cen._ ___ _ ._ Phone: (dll) 2fz_l?>y I <br /> I Total Cosl ta Install Dev�ce (Imm r,nnfracfor mvoice) 5 _�`�"�. � -- --� <br /> I, Ihe property owner, requesl to have the Cdy of Cverett Bachwater Prevenhon Device rebate check <br /> for Ihe inslallat,on ot Ihe device at Ihe above relerenceA property �dAiess be made payahle lo, and <br /> sent �o. lh� vendor spealied on lhe bar.k of�his (orm �y request�ng ihe rebate check be made <br /> payable to Ihe vendor. I agrce to the lollowmg <br /> 1 I �vill n�d recerve a rebale check dueclly from the Gly of Everelt <br /> 2 Assignmy paynien� o� lhe rebale lo Oie vendor does not exempl me(rom Bacl�waler <br /> prevenlinn D�:vice Rebatr. Prngr�m reqwrernents <br /> II autho� te the rMense of my rehale to ihe vendm listed on the back ol Ihis lorm pending <br /> approval of V�e compleled ��ckw:de� Prriventi�n Device reb�rte packol by the City ul [veretl <br /> r � <br /> �"�'��"�y'�`-`=,," — �- 7- /f <br /> Siynature of Properly Owner Dale <br /> L- - -- - -- - � <br />