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- . i <br /> i <br /> Backwater Prevention Device <br /> �' T Rebate Fr'ogram <br /> For internal Use: Pr'pject Number. <br /> Vendor Pa��ment Option For� <br /> Please complete both sides�of thc form <br /> Property O�nrner Section (please print): � <br /> — � <br /> � <br /> Property Ovmer Name /_�a�.}� �51 �, <br /> �-1 � h 1 l^'�I <br /> Property Address ZU`$ �I I v c;�y EVe(�� i Slat�e �� Zip� //�U� <br /> f� �U `� <br /> Alternale Mailing Address Ci State <br /> Po (�o�(W�� � �a�� I � w� z�� �1�'�y 6 <br /> 'Phone � ,y _3�� ' �ma�i q��,,�;@ AS�u<� P���e��� �cc <br /> � <br /> � <br /> I, the Property Owner, request lo have the City of Eve�ett Back��aler Prevention Device <br /> rebate clieck (or the installation referencec' at tlie Property Address be made payable <br /> to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br /> to the Vendor, I agree to the following: � <br /> 1. I will not receive a Backwater Prevention Devic i rebate check direcU�� (rom Ihe <br /> City of Everett. <br /> 1_. Assiyning payment of ihe Backwater Preventioii Device rebate to the Vendor <br /> does not exempt me from Backwater Prevenlio i Device Rebate Program <br /> rcyuiremenls. <br /> � � <br /> I a�dhorire the ralease of my rebate to the �endor IislLd on paye two of this form � <br /> pending approval of the completed Backwater Preven�ion Device rebate package by <br /> the Cily of Everett _ � <br /> v I J <br /> � <br /> 5ignatura of Properfy Owner I ! Date <br /> i <br /> Revisrd J/3/2014 � Page 7 of 2 <br />