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� Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (Ciry to ProvidoJ <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: 7�V��NnR 1�1����1we- <br /> Installation Address: �a�`t wl��� ��� <br /> Ciry: �'0�(f} State:��_Zip: Gj��)�( <br /> Mailing Address(iI dilforent): i v �� �3��0� <br /> City: 'E?�e�t�l Slate:�_Zip: �1�2U� <br /> Email: 2fMUv��tUinSZ@ O��UA.II -{�� Phone: (�Z'S) Zg� g I�� <br /> Tolal Co;t to Install Device(from confractorinvoico): 5 3��1�-1. �� <br /> I, Ihe property owner, raquest to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of l�io device al the above reterenced property address be made payable to,and <br /> sent to, the vendor specified on the back o(lhls fortn. By requesfing the rebafe check be made <br /> payable to Ihe vendor, I gree to the following: <br /> 1. I will nol receive a rebute check directly from the City of Everetl. <br /> 2. Assigning payment of Ihe rebate to thc vendor does not exempt me from Backwater <br /> Praventlon Devlce Robale Program requirements. <br /> I aulho�ize lhe release o(my rebate to the ve�dor lisled on Ihe back of this fortn pending <br /> approval of the compleled Backwater Prevenlion Device rebate packet by Ihe City of Evereft <br /> - gi� I�S <br /> Signal re roperty Owner Date <br />