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Backti�ater Prevention f�evice Rebate Program <br />Vendor P�yment Option Form <br />Project Number. (City fo ProvideJ <br />Please complete both�sides of the form <br />Property Owner Section: <br />Properiy Owner Name: j'h i�i '�•-{�- �• L 1; � P <br />Inslallation Address: q 3 0 �.� ��y�✓r <br />City: 1�. �c �z+t Stale:_jvj��_Zip: `7t�ZD j <br />Mailing Address (i(di8erent): <br />City: State: Zip: <br />Emaie O� IY• �k � ��; �c �/io�. [o� Phone: ( I z� Z�j 3" 3'' 0 3 <br />Total Cost to Install Device (from confractorinvoice): 5 3 G� ��— <br />I, the property owner, request to have lhe City of Everett Bar.kwater Prevention Device rebate check <br />for the installation of the device at the above re(erenced property address be made payable to, and <br />sent to, the vendor specifiedron the back of this form. By requesling the rzbate check be made <br />payable to ihe vendor, I agree lo the following: <br />1, I will not receive a rebate check directly from the City o( Everett. <br />2. Assigning paymenl of the reba[e to the vendor does not exempt me from Backwaler <br />Prevention Device Rebate Program requiremenis. <br />I authorize the release of my rebate lo the vendor listed on the back of lhis form pending <br />approval of the completed Backwater Prevention Device rebate packel by the Cily o( Everelt <br />Signature o( Property Owner <br />_ �S <br />Date <br />