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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number._ __ (City to Provide) <br /> Piease complete both sides of the form <br /> Property Owner Section; <br /> Property Owner Name: I �I � � C d��� L L � . <br /> Installalion Address: � � � �i L h �A v Q v P <br /> � <br /> City:� ✓��_�_State:��Zip: �� � (/ 1 <br /> i k F.{ �j <br /> Mailing Addmss (i(dille�ent): � � O � sT Vf� SY'� �r��— ��Q � <br /> c�cy:�Na l, � N, ���f�_ sta�e: W A zip:��`j'-��'-t1 D <br /> Email:�' - erv vi✓� l�r��t�,�oNPhone: (YJ� � �(y- D 0� <br /> Total Cost to Install Device (from contractorinvoiceJ: 5 <br /> I,the property o�vner, request to have the City of[verett Backwaler Prevenlion Device rebate check <br /> for lhe installation of the device at the above referenced property address be made payable to, and <br /> sent to, the vendor specified on Ihe back of ihis form. By requesting the rebale check be made <br /> payable to lhe vendor,I agree lo the followiny: <br /> 1. I e�ill not receive a rebate check directty(rom the City of[verett. <br /> 2. Assiyning payment o(the rebate to lhe vendor does not exempt me from f3ack�valer <br /> Prevenlion Device Rebate I'rogram requiremenls: <br /> I t�ulhorize lhe release of my rebate to the vcndor listed on Ihe back of this(orm pending <br /> approval of Ihe compieted Back�valer Prevention Device rebate packet by Ihe City of Everetl <br /> � �--... j��� I � v I y <br /> Signalure of Prorerty Owner Date <br />