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Backwater Preverttioh Device Rebate Program <br /> Yendor Payment Option Eorm <br /> ProJeCt Numbe.r. (Cily tb P/qW�e) <br /> Piease.coniplete boti�si:ci�s of Ehe form <br /> Property Owre�Section; <br /> Prbperty Ovmer Name: � 1L�'�1� <br /> InstaAaGDn AddCess � S 4� ���_� <br /> city: �V-QJ�P� Statet.�_ztp; 1 0 � <br /> Mailing/(ddress(NdifferenQ: <br /> Glb� � State: Zip: <br /> �meil: ,Phoner(. ) <br /> Totai Cost fo Inslall Device(trom coqtrecto�tnvolce):$ <br /> 1,the propetty awner,request Fo f�ave the Clty ofiEyereth BackWataf Preventlon Qevica rebate check <br /> iar the Installatlon af'!ha device at the above referenced property address be Inede pnyebie to,and <br /> Sent to;fhe.veradorspecifled on the b2ck ofthls form. By requesflng the rebate eheck be mede <br /> payabie In the vendor, I ag�ea to the tollowfng; <br /> 1. 1 wN noCfecCive e retiat�c(teoic directly from the City of Everett. <br /> 2. Rsgignfng payment of the rebate to the vendordoes not exempl me hom Beckwater <br /> Preventibn Device Rebate Prpgram requirements. <br /> I.auth�rae tfie releese of my rebate to the vendor Gsted an the baCk ot lh(5 forrn p@qping <br /> approval of the compleletl BackWate�Prevention Deyice rebate packet by the:City of Everek <br /> �Y'"�''�/ �L%I�Lf /d- / <br /> Signature oFPraperty Owner Date <br />