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Backwater Prevention Device Rebate Program <br /> f Vendor Payment Option Form <br /> Project Numter: _ (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: • <br /> PropeAy Owner Na�ne: f✓��,5 lv�1 <br /> InstallationAddress: 2� b� Ga� h� <br /> City:�V.e l��-�T Slate: �A' Zip:��j Z[� � <br /> titailing Address(rl diHerenf):_(fJ CJ ?J� l�t�i .��d 7�"� ��'t"1 3 O 3 <br /> CitY: ,��j'1 YVlla/� State: l/"� Zip: �d�8� <br /> Email:�/[t U� • O�S 0�'l �t��� •Cu�^^ Phone: (�U0) �I�I`6-7I�� <br /> Total C st to Install Device (from confracror irvoice): $ /O[JD - � <br /> I, the property owner, request to have lhe Ciry of Everett Backwater Prevention Device rebate check � <br /> for Ihe inslaliation of the device at the above referenced property address be made payable to, and <br /> sent lo, the vendor specified on the back of lhis(orm. By requesling the rebate check be made <br /> payable to the vendor, I agree lo lhe foltowing: <br /> 1. I will not receive a rebale check direcUy from the Cily of Evereft. <br /> 2. Assigning payment of the re6ate to the vendor does not exempl me from Backwater <br /> Prevention Device Rebate Program requiremenls. <br /> � <br /> I aulhorize lhe release of my rebate lo the vendor lisled on Ihe back o(this form pending � <br /> approval of the completed Backwater Prevention Device rebate packel by the Cily of Everett � <br /> % �/ d- /�_ <br /> Signalure o(Property Owner Date <br /> t <br /> i <br /> _ � <br />