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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Pro�ect Number _ _ __ (City fo Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> --- --- -- - - ---� <br /> / i <br /> Property Owner Name• �,����_�����___ —_ <br /> Installation Add�ess _ y[�_L��f���- — <br /> City: __�(��d���"—L.a�---- Stete IL�!t I------ Z������ <br /> �i Mailing Address (ildillererit)n���'1�--(�—�o?(r'��fXjQ.���_¢Yc�____— <br /> I City'��-�_ —_ State: f�C�_—_ Zip _-���1 — <br /> Email Phonecp"'')�_�_���� <br /> Tolal Cosl to Install Device(Irom contractor invoiceJ $ _____ .____._.__ . <br /> I,the properly owner, request lo have the Cily of Everett Backwater Prevention Device rebate check <br /> for the �nstallation of thc device at Ihe above referenced property address be made payable to, and <br /> sent to,the vendor specified on the back o(this form 8y requesling the rebate check he made <br /> payable lo the vendor, I agree to thr,following <br /> 1 I will nol receive a rebate eheck direcUy from lhe CAy of Everett <br /> 2 Assign�ng payment ol Ihe rehate ta the vendnr does nol r.xempt me from Beckwater <br /> Prevenlion Device Rebate Program requuemenls. <br /> I authorize the rolease of my rebale to the vendor lisled on the back ol lhls lorm pending I <br /> approval of lhe oompleted Backwater Prevenlion Devicr, rebate packet by the City of Everett <br /> % <br /> -�_- - �/g �� � <br /> Signalure ol Propehy Owner Date <br />