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' , 1 . _ <br /> Backwater Prevention Device <br /> Rebate Program � <br /> For intemel Usa: ProJect Number: I <br /> Vendor F'ayment Option Form <br /> Please complete botl� sides oi the fortn <br /> Property Owner Section (please p►fnt): <br /> �� n <br /> Prope�Ovmer I�ame �� �� �j�,�OI <br /> 2zo CPq�Cr 51- �v�rc <br /> PropeRyAddress City State Zip <br /> Altemate Malling Address City Stata Zip <br /> Phone 6y ou _ 7µ�y Eme� <br /> I, the Property Owner, request to have the Ciry of Eve�ett Badcwater Prevenlion Device <br /> rebate check for lhe instaliation referenced at the Property Address be made payable <br /> to, and sent to, ihe Vendor.By requesting the Incentive/rebate check be made payable <br /> to the Vendor, I agree to the Pollowing: <br /> 1. I will not receive a Backwater Prevention Device rebate check directly irom the <br /> City of Everett. <br /> 2. Asslgning payment of the Backwater Preventlon Device rebate to the Vendor <br /> does not exempt me from Backwater Preventlon Device Rebate Program <br /> requirements. <br /> I authorize the release of my rebate to fhe Vendor listed on page two oi thfs fortn <br /> pending approvai of the compieted Backwater Prevention Device rebate padcage by <br /> tho City of Everetl <br /> iz- �- i/ <br /> Signefuwo/Prope Owner Date <br /> Revlsed B/312014 Page 1 oi Z <br />