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/;w��� Backwater Prevention Device Rebate Program <br /> � Vendor Payment Option Form <br /> Projecl Numb��r _ __ _ (Ciry fo Prov�de) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> -- --- -. . _ . , -- ---- <br /> ProPerty Owner Na ne ���� ��� - ---- <br /> � � ( � � � <br /> Installalion Address. -�� ,�,'[UN [___ <br /> � City: L�.�u--t`�__ _ - State' (�1�}� Z�P�'���_ — . <br /> � Madmq Address (Il dillerenfl _ ------------ - ----- <br /> City State: _ _ 7_ip _ <br /> �{ n ,,,� � /_ n ��/ Phonc p� L�o -��_/� <br /> Emad: 11�/�'t' � � 4"�lM-1 _l'=�- --- �- <br /> Total Cost to Inslall Device (Irom contractor mvoice): 5 _ __ _. _ - <br /> I, ihe property owner, iequesl lo have �he City ot Evetelt Bar.kwaler Prevention Dewr.e rebate check <br /> inr lhe mstallaGon o(thr, device at Ihe ahove roferenced property address be made payable lo, and <br /> sent to, lhe vendor specilied on the back of thls form 6y requesling the rebate check be made <br /> payable lo Ihe vendor, I agree to Ihe following <br /> 1 I wdl not receive a rehate check d�rectly irom the City o(Everett <br /> 7 ASslgnmg p�yment ol the rr.hate to lhe vr.ndor does not ezempt me from Backwater <br /> Prevention Device Rr,bate Program requirem�nls. <br /> I authorire the release o(my rebate lo thc vendor listed on the beck ol thls lorm pundmy� <br /> approval of the completeA Backwaler PrevenUon Device rebate packet by Ihe City of Everett <br /> / <br /> � l / � /�� <br /> � � �� <br /> Signature o roperty wner Dale <br /> � --- - - - <br />