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� B�ckwater Prevention Device <br /> a Rebate Program <br /> For internal Use: Project Nurnber: <br /> Vendor Payment Option Form <br /> Piease complete both sides of the form <br /> Property Ovjner Section (please print): <br /> Property Owner Name��, , \� � � ,nn��� <br /> \J l �1_l <br /> Property� A��ss City State � � ^��O I <br /> (�1�� �� <br /> � Alternate Mai�g Address City State Zip <br /> '' C'1 I ✓:u� ? S� -� � � �„�.^- �' �� 6)_ > � �, <br /> 2 � �,z, - <br /> Phone Email: : t:,� ���/?;��r r C� �'�::%..5 f,� . 7�- <br /> S1C(n�._y��QR3 � <br /> 1, the Property Owner, request to have the City of Everett Backwater Prevention Device <br /> rebate check for the inslaliation referenced at the Properly Address be made payable to, <br /> and sent to, the Vendor. By requesling the incentivelrebale check be made payable to the <br /> Vendor, I agree to the (oilo�ving: <br /> 1. I will not receive a Backwater Prevention Device rebate check directiy from the <br /> City of Everett. <br /> 2. Assigning payment of the Backwater Prevention Device rebate lo the Vendor <br /> does not exempt me from Back�vater Pr2vention Device Rebate Program <br /> requirements. <br /> I authorize the release of my rebate to the Vendor listed on page two of this form pending <br /> approval oi lhe completed Backwater Prevention Device rebate package by the City o( <br /> Everett �--� /! � � <br /> i l , .... �� _ _ - ? i. , � / S� <br /> . / �J <br /> Signature of Property Owner Date <br /> Page 1 of 2 <br /> Revised 913f2014 <br />