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i <br /> � <br /> Backwater Prevention Device � <br /> Rebate Program i <br /> i <br /> For Intomai Use:Pro)ect Number: � <br /> Vendor Payment Option Form � <br /> Please complate both sidea of the form I <br /> property Owner Section (pleaae print): I <br /> � n �ra ✓�Le. R AmburGJ /�IZrri L��2St �nbt.uziy._ <br /> Pro ert Owner Name <br /> �r � <br /> : r EvR.x.�.tt W►� R'S�I <br /> PropeAy Address City Stale Z�p <br /> Altemate Meili�g Address Ciry State Zip f <br /> �,a� �3� -r�s-�s � - I <br /> Phane Email <br /> 1, the Property Owner, request to have the Cily oi Everett eeckwater Prevention Device <br /> rebate check for the installaqon referenced at the Property Address be made payable <br /> to, and sent to,lhe Vendor. By requesting lhe fncentivelrebate check be mada payable � <br /> to the Vendor, I agree to the follawing: <br /> 1. 1 will not recelve a Beckwater Preventfon Device rebate check directly trom the <br /> Ciry of Everett. <br /> 2, Assigning payment of the Backwater Preventlon Device rebate t��the Vendor <br /> does not exempt me Irom Backwater Prevention Device Rebate Program <br /> requirements. <br /> I authorize the release oi my rebate lo the Vendor listed on page lwo of this fortn ' <br /> panding epproval of the completsd Backwater Prevention Device rebate package by <br /> ihe City o(Everett <br /> �..WVu. W�✓�Yv1�t-b'IG�U — Io-27-14 <br /> Signafure o(Properly Owner Dafe <br /> Page 7 of 2 <br /> Revlsed 9/3IZ014 <br />