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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projec! �lumbec _ (Ciry fo Provide) <br />Plfaase complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />Installation Address: ,5 Y// G��/bi> �7VP.- <br />� � — <br />Cily: _�✓C✓G� __ Stale: /�_ Zip: %g d �� <br />Mailing Address (if diflerenf): .�.3� /L� ����� <br />Ciry: �Clr�! ,G State: � z�p: r?P/ 33 <br />Email: _�- +� C�(� ?✓'�a; I. C✓N^ Phone: (av�) 3� L- k 9x3— <br />Total Cost to Instatl Devico (f�om contractor invoiceJ: $�sc�. � <br />I, the property owner, request to have the City of Everetl Backwater Prevention Device rebale check <br />for lhe installation of the device at the above referenced property address be made payable to, and <br />;ent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. I will not receive a rebate rtieck direcUy trom Ihe City of Everefl. <br />2. Assigning paymenl of the rebate lo Ihe vendor does not exempt me trom Backwater <br />Prevention Devicc Rebate Program requlrements. <br />I authorize the release of my rebale to the vendor listed on lhe back oi this form pending <br />approval of lhe completed Backwater Prevenlion Device rehale packel by Ihe City o( Everc:tt <br />Owner <br />�—/G / 3� <br />Dale <br />