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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Number. _ (City fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Prope�ty Owner Name: C�- M�i'=��% <br />InstallaGonAddress: sS�� C�i� �"�L <br />City: ���%� Statz: W!} Zip:_ Q��3 <br />Mailing Address (if diHerenQ: <br />City: State: <br />Email: Phone: (y� �3- S7'77 <br />Total Cost to Install Device (lrom contractorrnioice): $ a�V"1 +v� � <br />I, the property owner, r�quest to have the Cily of Everett Backwater Prevention Device rebate check <br />for the installation ot the device at lhe above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesling the rebate check be made <br />payable to the vendor, I agree to the followiny: <br />1. I will not rece�ve a rebate check directly trom the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />PreventiomDevice Rebate Program requirements. <br />I authorize the release of my rebate to the vendor Iisted on the back of this (orm pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />�i�' /�/�b / <br />Signature of Property Owner <br />Dale <br />