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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> ProJect Number. (Ciry to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> i <br /> Property Owner Name: —��_�[?g,roh <br /> installation Address: �Gz7J �O��N /iv� <br /> Cily: l%VU��'�' State:�J _Zip: ='($�O� <br /> Mailing Address(i(diflerenf): <br /> City: State: Zip: <br /> Email: ��;� �e�ao.� kJ �roa-�.:� . �� Phone: (.Zcx,,l a`q5 - `6`��I <br /> Total Cost to Instaii Device (from contracto!invoice): S�`T3�• o (1 <br /> I,the property owner, request to have lhe City of Everett Backwater Prevention Device rebate check <br /> for lhe installation of the device at lhe above referenced property address be made payable to, and <br /> sent lo,the vendor specified on lhe back ot this form. By requesting the rebate check be made <br /> payable to ihe vendor, 1 aqree to the following: <br /> 1. I will not receive a rebate check directly irom the City of Everefl. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> ! <br /> I authorize the release of my rebate lo the vendor listed on the back of this form pending <br /> approval of ihe completed Backwater Prevention Device rebate packet by the Ciry of Everett <br /> �C���j% '�Zr, � �2.-�- I�{ �� <br /> Signature of Property Owner Date <br />