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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Number. ___(City fo Provide) <br /> Please complete bath sides of the form <br /> Property Owner Section: <br /> 5•7�✓�+ .J - — <br /> Property Owner Name: � /d _ <br /> Installalion Address: ��/�� �� — <br /> Cily: _�/r/t.{-f Slate L//�' Zip:�� <br /> Maili�g Address(il diNerenf): <br /> Clty: Slate� Zip_ - <br /> Einail: Phone: ( ) �.3� � <br /> Total Cost to Install D�vice (lrom contracfor invoice): $ �� fo�.� —� <br /> I, the property owner, request lo have lhe City of Everell Backwaler Prevention Device rebate check <br /> for Ihe insiallation ol the device at the above re(erenced property address be made payable to, and <br /> sent to, the vendor speciGed on the back of Ihis form. By requesting the rebale check be made <br /> payable to Ihe vendor, I agree to tlie follo�ving: <br /> t I will not receive a iebate check direcUy (rom Ihe Cily oi[verett. <br /> 2. Assiyning paymenl ot the rebate to the vendor does not exempl me irom �ackwalcr <br /> Prevention Device Rebate Pwyram requirements. <br /> I aulhodze ihe release of my rebalc lo the vendor listed on lhe back of lhis torm pending <br /> approval o(Ihe compleled Backwater Prevention Device re6ale packet by the City of Everett <br /> � <br /> 5 � <br /> �' f / , j , � /r_. <br /> �� <br /> , .� , <br /> � SignaWre of Prope 1y O�vner Dete <br /> � <br /> � <br /> ,. \\ — <br />