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' ' i . <br /> � � Badkwater Prevention Device <br /> I Rebate Program <br /> iFor internal Use: Project Number:_ __ <br /> Vendor Pa��mentiOption Form <br /> Please�complete both sides of the form <br /> Property Owner Section�(please print): <br /> � db✓�2. <br /> Property Owner Na e� : �� c�o <br /> �.e`a.�f � / <br /> Property Address j City Slate 2ip <br /> Altemate Mailing Address City State ZiP <br /> = b .a A� � �o� <br /> <Piione �Email <br /> I, the Property Owner, request a have the City of Everett Backwater Prevention Device <br /> rebate check for the installatio referenced at the Propert�- Address be made payable <br /> to, and sent to, the Vendor. By rf:questing the incentfve/rebate check be made payable <br /> to the Vendor, I agree to the fo lowing: <br /> 1. I will not receive a Bac �3ter Prevenlion Device retrate check directly from the <br /> City of Evereft. <br /> 2. Assigning payment of th�Backwater Prevention Device rebate to the Vendor <br /> does nol exempt me fro Backwater Prevenlion Device Rebate Program <br /> requirements. � <br /> i <br /> I aulhorize the release of my , bate !o ihe Vendor listed on page two of lhis form <br /> pending approval of the comp)eted Backwater Prevention Device rebate package by <br /> the City oI Everett � <br /> I <br /> J <br /> _ / i.y ut <br /> `Signature ol Property Owner � �Dafe <br /> i <br /> I <br /> � PaOe� or 2 <br /> Revised 9I312014 � <br />