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. i <br /> . � Backwater Preu�ntion Device <br /> � � d Rebat� Program <br /> � <br /> � For internai Use: Project Number: <br /> � _ <br /> Ve�,ndor Pay�ment Option Form. <br /> i <br /> Please complete both sides of the form <br /> Property Owner Sectian (please print): <br /> � <br /> —' ��_��� ,�I�C��� <br /> Pr e Ova me <br /> �.I _ . ���.; (,v�I� 9�i <br /> .�i�-���:� Ql�n <br /> �Pmperiy`Addre�s �y} tState ;7_ip� <br /> Aitpmate Maili�g A rdd ess �Gity State �Zip <br /> I S`Phbne� '�� � �nail 1 r, �. <br /> i � � � CJ , ' <br /> I, the�Property Owner, request to have the City of Everett Backwater Prevention Device <br /> rebate check for the installation referenced at the Prcoerty Address be made payable <br /> to, and sent to, the Vendor. By requesting the incentiee/rebate check be made payable <br /> to the�Vendor, I agree to the following: <br /> 1. I will not receive a B�ckwater prevenlion Device rebate check directiy from qie <br /> i City of Everett. <br /> 2. j Assigning payment of the Backwater Prevention Device rebate to the Vendor <br /> ' does not exempt me from Backwater Frevention Oevice Rebate Progr;.m <br /> requirements. <br /> � <br /> I aul,iorize the reiease of my rebate to the Vendor listed on page two of this form <br /> pending approval of the completed Oackwaler Prevention Uevice rebale package by <br /> the Gity of Everett <br /> —' ' � v S <br /> ; <br /> � Signatu`m:of PPoj�er1ty Owne� Date <br /> � ) y � <br /> � <br /> 1 <br /> f <br /> Revisedi91312014 Page 1 of 2 <br />