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Pro�ect Numbec <br />Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />(Cify (o P�ovide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />Installalion Address: <br />Ciry: Z�d/�Q� � State. ,�� 2ip:�X� <br />Mailmg Addrees (il diNerent): <br />City: <br />Email. <br />Slate: <br />Total Cost to Inslall Device (from contraclor invoice): <br />Phcne: ( f lS� 3/%� �i�J�i- <br />� �i ���- � <br />I. Ihe property owner, request to have Ihe Cily of Everett Backr�ater Prevention Device rebale check <br />for Ihe inslallalion of lhe device at the above referenced property address 6e made payable lo, and <br />sent to, the vendor specitied on Ihe back of this form. By requesting the rebate check be made <br />payable to the vendor, I agme lo ihe folloeeing: <br />t. I�vill not receive a rebate check directly from the City oi Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Re6ale Program reqwremenls. <br />I au;horize lhe release of my rebate to Ihe vendor listed on the back of this lorm pending <br />approval o( the completed Backivaler Prevention Device rebate packet by the City of Everelt <br />j�� �� ��� <br />Signature of Property Owner <br />� <br />Date <br />