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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Numhec (City to ProvideJ <br />Please complete both sides of the form <br />Property Owner 5ection: <br />Propert,� Owner Name: 7 � <br />Installation Address: S r 1- l� L�v t <br />U <br />t <br />City: �L tQ��7 ) Stale: L�.✓1 Zip: � GLv7 <br />Mailing Address (il di(ferenfJ: <br />City: <br />Email: <br />�-"' <br />State� <br />Phone: ( <br />Tolal Cosl to Install �evice (Ironr conlractor invoice): S Z �` <br />� �9� i <br />I, ihe property owncr, requesl to have �he City of EvereU dack�vater Prevention Device rebate check <br />for the installation o( the device at the above referenced property address be made payable to, and <br />senl lo, the vendoi speci(ied on the back of lhis form. By requesting Ihe rebate check be made <br />payable to lhe vendor, I agree to Ihe following: <br />1. I will not receive a rebats check direcqy (rom the City of Everelt. <br />2. Assigning paymenl of the rebale lo the vendor does nol exempt me fror� Backwater <br />Prevenlion Device Rebale Program requirements. <br />I aulhorize Ihe release of my rebale to the vendor listed on lhe back ol lhls form pending <br />approval of the compleled Backwaler Prevention Device rebatc packet by the City of Everett <br />v /��'�`�j S �.�.� <br />Signature o( Properly O�vner <br />-Z�LL—�1� <br />Dale <br />