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�— <br /> Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (Cify to ProvideJ <br /> Please complete both sides of the forrn <br /> Property Owner Section: <br /> Properly Owner Name: �0.1 YIC�G� �� — ��aV Y1'10�'1('1 ___ _ <br /> InstallationAddress:���- r.��� 7'S�P�'�l,L� <br /> City: s��� State:��_Zip:_� ZO <br /> Mailing Address(iI dilferenQ: �A-V1'1� ._ <br /> City: State: Zip: <br /> Email: Phone: (4�) 2�JZ' �'�_. <br /> Total Cost to Install Device (Irom contractorinvoice): $ <br /> I, the property owner, request to have the�City of Everett Backwater Prevention Device rebate ch?ck <br /> for the instalhtion of the device al the above referenced property address bc made p2yabie to, and <br /> sent to,lhe vendor sper.ifed on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the foilowing: <br /> 1. I will not receive a rebale check directly from the Cily of Everelt. <br /> 2. Assigning payment of lhe rebate to lhe vendor does nol exempl me (rom Backwaler <br /> Prevention Device Rebate Program requirements. <br /> I authorize lho release of my rebate to the vendor Iisled on Ihe back of lhis form pending <br /> approval of the completed Backwaler Preventi�n Device rebate packel by lhe Cily of Everetl <br /> �1 4/i� �- ti Ci' (9.�iS.� n. A� C_/� � �� <br /> Signature of Property Owner Date <br />