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i <br /> i <br /> � Backwater Prevention Device Rebate Program : <br /> Vendor Payment Option Form � <br /> Project Numbcr: (Cify fo Provide) � <br /> , <br /> � <br /> Please complete both sides of the form � <br /> i <br /> Prope►ty Owner Section: i <br /> � <br /> Property Owner Neme: /"��5°�'` pjq��� � I <br /> InslollalionA�dress: 1`�[(�4 �o.�✓ �vE __.__ � <br /> i <br /> / i <br /> City: IL-��� Stalc: l�{� Zip���Z�� � <br /> i <br /> Mailiny�ddress(il diNerenl): � <br /> Clty: State: Zip: _._—._— <br /> � ! <br /> Email: � D�1.�Qe-�-G�__�_Q W� •(.�M Phone�(�25� 1'�`�' Z4�'� I <br /> Total Cost to Install Device(/rom confracfor invoicc):S �� ��'`� � __. _— ! <br /> 1 <br /> .._ "_ -__. __.��___-____"___ _-"_ I <br /> I, tho proporty owner, requesl ta have Ihe Gty of Evorotl Backwalar Prevention Devico rabnle chack ' <br /> for lhe inslnllation o(lhe devico al the above re(oronced property addross bo made peyable lo, and ! <br /> sent lo,lhn vundor epecitir.d on lhe hack of lhis form.By roqueslinp thc rebate check be made i <br /> payable to lhe vondor, I nc�rec�lo Iho following: ' <br /> 1. I wiU nol receivo a rebate check direclly from thr.Cily of Evmelt. � <br /> 2. Assigninp paymunt of Iho rehato lo the vi:ndor does not exompf mo(rom BHckwalcr <br /> Prevonlion Duvico Rebalc Program rcyuiremonts. � <br /> _. --- _ --. __. _ i <br /> I oulhoriz�Iho roleaso nl my rebatn tc�Ihe vendor Ilsted on lhe back ol this torm pr,nding � <br /> appioval ol lhe compl�led Backwolor Pravonlion�uvico robala packet by Ihe Cily ol Everett i <br /> ( <br /> �l�F��� Z� - 's� : <br /> Signalure oi Property Owner � Date � <br /> i <br /> --- — ---- - - - — - -- i <br />