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Backwater Prevention Device Rebate Program <br />00 L Vendor Payment Option Form <br />Project Number: _ (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name:KIAA4�b <br />R't KuMR. <br />�rR�AL. <br />Installation Address: �102 C6Lg7 AVENU E <br />City: i5VE1C6T I State: (") & Zip: 92a0g <br />Mailing Address (if different): <br />City: <br />Stale: Zip: <br />Email: Gl l.o_Arlrwra.cQQC yakcjo- Cow.. Phone;&W 903-0399_' <br />Total Cost to Install Device (from contractor invoice): 5 aka [ - 8 K <br />I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specifiedion the back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. 1 will not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the completed Backwater Prevention- Device rebate packet by the City of Everett <br />03�v3jIS' <br />:signature of -Property Owner Dale <br />