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� Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. _(Ciry to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: �IC l��L�- u�7�'���`�T <br /> Installafion Address: _��D _gL�72'�^� ��J� <br /> @�(►�/LrZT State: UI/} _Zip._ �20I <br /> City: --- --- - — <br /> Mailing Address(il dJ//erent): _� ___—__ .. <br /> City: Stale: - -- Zip: - — _-_- <br /> Email: Phone: ( ) _ _ _ <br /> Total Cost to lnstall Device (Irom confmctor invoiceJ: $ 2 7�� � <br /> I, the property owner, request lo have ihe City of Everett Backwater Prevention Device rebale check <br /> for lhe installalion of the device al Ihe above referenced pioperty address be made payable lo, and <br /> sent to, lhe vendor specified on Uie back of this form. By reyuesting the rebate check be made <br /> payable to lhe vendor, I agree to the tollowmg: <br /> 1. I will not receive a rebate check directly from Ihe City ol Everett. <br /> 2. Assigning payment ol the rebate lo lhe vendor does nnt exempt me from Backwalr.r <br /> Prevenlion DQvice Rebale Program reyuirements <br /> I authorim thr, release af my rebato to the vr.ndor IistoA on the back of Ihis form pending <br /> approval ot the completed Backwaler Prevention Device rehate packet by Ihe City o(Everelt <br /> /`l"-�-- c"�f �- � z - LL.— <br /> Signature o(Property Owner Dato <br />