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�w��'�"" Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Forrn <br /> Pro�ect Number _ _ _ _ __ �Gty to ProvideJ <br /> i <br /> Please complete both sides of the form � <br /> i <br /> Property Owner Section: <br /> � �� . <br /> ProperlyOwnerName' �" �l��Y+�oc� `� �ryJ � <br /> Installetion Address ����4 -« �-C___ _ <br /> City:��1��� State: ��'" Zip _��d J / <br /> tvlailing Address(i!dillerenf):_ ____ __________ __ <br /> � <br /> � Gty:--- --- State: - Zip, ----- - <br /> IEmail: (� �., �cx.� ✓+ •<�:� Phone: �11'� 3��7_ <br /> _ T J~ <br /> I Total I Cost to Install Device(liom contracforinvoiceJ: $_� (,[�. _ _ <br /> I, Ihe properly owner, requesl to have the Cily of Everelt Backwater Prevention Devicc rebate check <br /> (or the installation of lhe device at lhe above referenced property address•be made payable to, and <br /> sent lo.the vendor specified on the back of this form. By requeslmg the rebate check be made <br /> payable to ihr, vendor, I agrec to the following <br /> 1. I will not rer.erve a rebale check directly from Ihe Cdy of Everett. <br /> 2. Assigning peyment of lhe rebale to lhe vendor does not exempt me from Backwaler <br /> Prevenlion Ocvice Reba�e Program requirernanis. <br /> I au�honze�he release o(my rebate to the vendor listed on ihe hack of this torm pendmg <br /> approval o(lhe compleled Backwater Prevention Device rebale packel by the Ctly of Fveretl <br /> � <br /> �� <br /> ----- - 3 � 3/-�s ' <br /> Signalure of Property Owner Date <br />