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� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Numbec (City to ProvideJ <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />Inslallation Address: ��/ ��I�ON� <br />City: ,�✓L!'Gli' State: �_ <br />Mailing Address (if diNerenf): <br />Cily: Slale: Zip: <br />Email: ��IOG�C��lLS%�%/!9�(LX�� Phone: (�(%j� �/(�—D 7� �+ <br />Tolal Cost to Install Device (bom contractorinvoiceJ: $ <br />I, the properly owner, request to have the City of Everett Backwaler Prevention Device rebate check <br />for the inslallalion of ihe device at lhe above referenced property address be made payable lo, and <br />sent to, the vendor specified on the back of Ihis form. By requesting Ihe rebate check be made <br />payable to the vendor, I agree to Ihe toilowing: <br />1. I will nol receive a rebale check directly from the City of Everett. <br />2. Assigning paymenl of Ihe rebate lo Ihe vendor does nol exempt me �rom Backwaler <br />Prevention Device Rebate Program requiremenls. <br />I aulhonze the release oi my rebale lo lhe vendor listed on ihe back oF this form pending <br />approval o( the compleled Backwater Prevention Device rebate packel by Ihe City of Everetl <br />� <br />Signature of Properiy wner <br />Y� W r/ l <br />Da1e <br />