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_,, . <br /> . . ; <br /> Bac;kwater.Prevention Device <br /> � Rebate Program <br /> For internal Use: Project Number: <br /> Vendor Payment i0ption Form <br /> Please�complete both sides of the�orm <br /> Propecty Owner Section �(please print): <br /> U �n �1 ��2��V1'�dl� <br /> Property 0 er Name <br /> —�--�0`t� �s:����ic lA-J �- — <br /> Proper�y,A�r� � �' i St� � Zip <br /> �� � ��� <br /> Alternate Mailing Address City State Zip <br /> Phon �d � Email �h����������1 �� <br /> I, the Property Owner, request do have the Cit��of Everett Backwater Prevention Device <br /> rebate cneck (or the installatio� referenced at the Property Address be made payable <br /> , lo, and sent to, the Vendor. [iy�requestirg the inceiitivelrebate check be made payable <br /> , to the Vendor, I agree to the following: <br /> 1. I will not receive a Backwater Prevention Device rebate check directly from the <br /> City of Everett. <br /> 2. Assigning payment of the Backwater Prevention Device rebate to the Vendor <br /> does not exempt me froin Backwater Prevention Device Rebate Proyram <br /> requirements. <br /> I authorize the release of my rebate to the Vendor listed on page two of this form <br /> pending approval of the completed Backwater Prevention Device rebate package by <br /> the City of Everett <br /> r ' <br /> � - <br /> �—� � <br /> CSignat`u�e'olProperty0 ner.;,�_` ['Da`te`—`.� <br /> _ ' � _---..-._._._�� ' <br /> ���� <br /> � • Page 1 of 2 <br /> Revised 913/2014 <br />