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�_ <br />Backwater Prevention Device <br />Rebate Program <br />For internal Uso: Projecl Number. <br />Vendor Payment Option Form <br />Please compiete both sides of the form <br />Property Owner Section (please print): <br />�tl l� „�, �s �� L� c. — <br />Property Ovmer N�]ame �✓ere� '.`d jy1,� <br />� ��% �ur�i /hf/i�1Q �tln i. _ W �1 1U "`'� I <br />Property Address <br />City Slale Zip <br />Alternate Mailing Address Cily Stalu Zip <br />�=-�_d / / / bLYL� ��S%t_i'����-Cd �a-t-- <br />Phone Finail <br />I, the Property Owner, request to have the City of Lverett Bac,kwater Prevenfion Device <br />rebate check for the installation referenced at thc Property Address bc rnade payable <br />to, and sent tn, Ihe Vendor. By requestiny the incentive/rebate check be made payable <br />to the Vendor, I a�rce to the followinc�: <br />1. I will not receive a Qackwaler Prevenlion Device reuale chock directly irom the <br />City of Everetl. <br />2. Assigniny payment o( lhe k�ackwater Prevention Device rebate to lhe Vender <br />does not cxempt me from 13ackv,�aler Prevention De:vice Rebale Proyram <br />requirements. <br />I aulhnrize the release of my rohate to lhe Vendor listed on pagc lvdo of lhis form <br />pending approval of the completed Ba�kwater Prevention Devic;e rebate package by <br />lhe City of Evereit <br />u^^��l�LwfJ�-y��ana�y__ ����,%r✓ __ 2 �S' _� <br />— � - <br />Signature of Pmperly Owner Uafe <br />