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����'-"" Backwater Prevention Device Rebate Program <br /> ` Vendor Payment Option Form <br /> Projecl Number __ _ ____ (Gty fo Prowde) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> �- -- - — - --- — -- <br /> Property Owner Narne: �Q R n� ' ' �e��!` �� + �L__. <br /> Installalwn Address: _ o�,�D�_�(��'__1�L�,— <br /> Cily �{1b'_� _ State(dl�l�- Z�P' rf�,�.�-- — <br /> Mailing Address (ild�Herent) _____ ______.___ _____ — <br /> � <br /> GtY: _... Slate --- - Ti� — <br /> EmaiPl.._�_t-�rrrr.-'°�1��"!�n'���—or _� Phone ( ) . 'Z.�20� <br /> Total Cosl to Inslall Device (bom confr�cfor invoice). $ _ __,r�4� '"�' `��- <br /> �—--- -- -- -- - --._ ---------- _ - � <br /> I, the property owner, request to have the Gity of Everetl Backwater Prevenlion Device rebate check <br /> (ur the inslallahon of the dewce at the above referenced property address be made payable to, and <br /> sent!o, �he vendor specdied on IhP :,ack of this(orm By requestinc�the rebate check be made <br /> payable to Ihe vendor, I agree lo the following: <br /> t t wdl no� recewe�a rebate check direcUy trom ihe Cily of Everetl <br /> 2. Assiyning paymenl ol �he rebate to Ihe vendor dor.s not exempl me from Backwater <br /> Prevention Device Rebale Program reqwrements. <br /> I authorize the release ol ciy rebale to the vendui lisled on Ihe back o(ihis torm pending l <br /> �pproval oi lhe completed Backwater PrevenUon Dewce rebate packet by the Crty nf Evered <br /> � ��� �> : <br /> : ����,�✓ — �" / 9 � l 5 _ <br /> Signalure ol Pioperty Owner Date <br />