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� <br /> � Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Number: ___�______ (Citylo Provide) <br /> Please r.omplete both sides of the form <br /> Property Owner Section: <br /> Properly Owner Name: G�!ILlL _���� <br /> Inslallalion Address: �A/ � ���h�9N � �� <br /> Cily:JL�C�.6Ll �"'' --—Stale: � _ Z�P'_..7 �ab� <br /> Mailing Address(il diHerenf): __ _. <br /> Cily: State: Zip: <br /> Email: ___ Phone. �� �`~� g��/ <br /> Total Cost to Inslall Device (Irom confrar.lor invo(r.e): $�s� ' � <br /> I, Ihe property owner, request lo have Ihe Ci�y ol EvereQ Backwaler Prevenlion Device rebate check <br /> for ihe inslallalion of the device at the above referenced property address be made payeble to, and <br /> sent to, the vendor specitied on the back of Ihis torm. ay requesUng the rebate check be made <br /> payable lo thc vendor, I agrec lo the following: <br /> 1 I will not receive a rebate check diredly irom lhe City of Everelt. <br /> 2. Assigning payment of Ihe rebate to Ihe vendor does not exempt me from Backwaler <br /> Prevention Device Rebele Program requirements. <br /> I aulhorize Ihe rcicase of my rebate to the vendor lisled on Ihe back ol Ihis (orm pending <br /> approval of the completed�dackwater Prevention Devir.e rebate packet by the Cily ol Fvere�t <br /> � <br /> --�,�� " ' �/S <br /> Signalure of Property Owner Date <br />