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Backwater Prevention Device Rebate Program � <br /> Vendor Pa� ment Option Form � <br /> Pro�ect Number __ (Gly fo ProvideJ <br /> Please comEAete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name._ U� (� IQ,�}� �( t' 17�Q,(,�1.� <br /> Installat�on Address- 'J �� �� � E•k��� �� ������� <br /> city: ���.��� state: UJG . z�p: �� b'�bl <br /> ; <br /> hlailing Address(il diNerenQ __ _ ' <br /> Cily ,- --_-- Slate: Z'P:_ � <br /> Email: Phone: ( ) <br /> Tolal Cost to Inslall Device (�rom contracfur invoice): $ <br /> I, the property owner,roquesl to have the Ciry of Evmett Backwater Preventiun Dovice rebate check <br /> for the installalion of 1he device al the above relerenced property address he made payable to, and <br /> sent lo, Rie vendoi speciGeA on the back ol�his form By requesUng the re�ate check be made <br /> payablc lo ihe vendor, I agree to Ihe,following <br /> 1. I will nol receive n rebate check directly fwm the City o(Fverett <br /> 2. Assigning p�yrnent of lhe rebale lo the venAor does not exempt me Irom B�ckwaler <br /> Preven�ion Devir.e Rebate Program reqwrements. <br /> I author �e thc� release ol my rehale tn the vendor listr,d on.the back ol lhis lorm pending <br /> approval oi Ihe compleleA Backwater Prevention Uevlce rebate par.kel by the Cily ol Everett <br /> � �.�=�, I - �� L� r� <br /> Signature of Property Owner Date <br />