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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Number. (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Propeity Owner Name: S �� C� rv �S <br /> Installation Address:� [ f� 1'�cC 0. <br /> City: � �� State: �� _Zip• �a0 � <br /> MailingAddress (ifdii/erent): �"��� �`�`�"1/ D � <br /> City: �Ne-�-� State: _�Zi� 'l� � a-o O <br /> Email: 5 �-P�1 e C� �o ��@ w`l✓�CttS��'hone: (�a"�a'�a—3 � i � <br /> — �^ � q B <br /> Tolal Cost lo Inslall Device(finm cont�acsor invoiceJ•$ C.4��•� "'r �l�� I'�� <br /> O�'a.( �O r D <br /> I, the property owner,request to have the City of Everetl Backwater Prevention Device rebate check <br /> for the installation o(lhe device at the above referenced properry address be made payable to, and <br /> sent lo, the vendor specified on the back of thjs form. By requesting lhe rebate check be made <br /> payable to lhe vendor, I agree lo lhe follo�ving: <br /> 1. I will not receive a rebate check directly from the City of Everett. <br /> 2. Assigning paymenf of the rebate to the vendor does not exempt me from E3ack�vater <br /> Prevention �evice Rebate Program requirements. <br /> I authorize the release of my rebale to the vendor listed on the back of this form pending <br /> approval of ihe completed Backwater Prevention Device.rebate packet by the City of Everett <br /> / l S=IS- . � <br /> Sign ture of Property Owner Dale <br />