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� <br />� <br />Backwater Prevention Device <br />Rebate Program <br />For intemol Use: ProJect Number: <br />Vendor Payment Option Form <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />?roperty Owner Name / / <br />,� �� � �v�P-It4 � �Yi9� `l �b 2 4 / <br />Property Address Ci:y State Zip <br />Altemate Mailing Address City State Zip <br />y?,S` 2. 62 943 � .n �Q/s � 3� Coh �s�'�7 N� <br />Phone Email <br />I, the Property Owner, request to have the Ciry of Everett Backwater Prevention De�ice <br />rebate chedc for the installation referenced at the Property Address be made payable <br />to, and sent to, the Vendor. By requesting the incentive/rebate chedc be made payable <br />to the Vendor, I agree to the following: <br />1. I will not receive a Badcwater Prevention Device rebate check directly from the <br />City oi Everett. <br />2. Assigning payment of the Backwater Prevendon Device rebate to the Vendor <br />does not exempt me from Backwater Prevention Device Rebate Program <br />requirements. <br />I authorize the release of my rebate to the Vendor listed on page two of lhis form <br />pending approval of the completed Backwater Prevention Device rebate package by <br />the City of Everett <br />Slgnaturie of PropeKy Owner <br />/ <br />Date <br />. Page 1 0( 2 <br />Revised 9/3/2014 <br />