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�Backwater Prevention Gevice Rebate Program <br /> Vendor Payment Option Form � <br /> Pro�ect Number. _ (C ty f�Prov�de) � <br /> � <br /> Please complet,a both sider. of the form I <br /> 1 <br /> Property Owner Section: <br /> --- - ------- ------ ----------------• <br /> i <br /> �' Pw�e�tY Ovrier Name � ., . _.1�,�< <br /> Instai'etion �ddres, �a� _ .�1���� .�v�.------------------ <br /> . j; City� �i�.� Slate�. �� � _Zip�. ZO -- <br /> I <br /> f�lad�ngAAdress (ildiHerent) ___�______ _ � <br /> i <br /> I ��ty ----- - / —_ State ___ 7_�p._..— <br /> ,� � <br /> I Email: ��K/� .� k�R� � L� Phone (�l�),�;�lp�Z_ � <br /> I II Total Cosl to Install Device (!rom contractor invoice) 5_pZ��l y� <br /> I -- --- ------'-- __- - - -- ---� <br /> I, fhe property owner, req�eat to have the C�ly of Everetl Backwater Prevention Devlce rebate check I <br /> for pm inslaliat�an of the device at the above referenced property address ba made payable to, and I <br /> sent lo, the vendor specifed on the back oi this fonn. By requesting the rebate check be made J <br /> payable to Iho vendor. I agreo to Iho fullowing � <br /> 1. I viill not n:ceive a rebate check direGly Irom ihe City ot Evereft. I <br /> 2. Assigning payment of ihe rebate to the vendor does nol eKempt me Irom D.�ckwaler 1 <br /> Prevenliun Devicu ReGcde Program icqui�emenis— � <br /> I <br /> I authonze ih@ re;eese o�my rCbe�e 10 thC VBntlor IISiCd On Irt@ batk of Ih151otm pentling I <br /> apU�oval ol lhe complelucf Backwatc�i Prov�ntion Oovku rebate packal by tho Clty ot Evorett � <br /> t <br /> I <br /> I jt�' / � � � ( 5 <br /> �i ture of Property Owner ate <br />