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Backwater Prevention Device Rebate Program <br /> � Vendor Payment Option Form <br /> Project Number:______________ (Cify to Prov.%dei <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> � Property O�vner Name N%nics_ �:z rB � <br /> Installalion Address: '��gi7n f, ��,� <br /> City: _�ve':t�i{- Slale: Wii Zip:���i_f <br /> �vtailing Address(if di/(erenf): <br /> � City: Slate' Zip: _ <br /> Finail: Phone: (3Lv) �sZ�i �6� <br /> ITolal Cost to Install Device (from contractorinvoice): 5 2�Soo� <br /> I, the property oemer, request to have the City of Everett Backr�ater Prevention Device rebate check <br /> for the installation of the device at lhe above referenced property address be made payable to, and <br /> sent to, the vendor specified on the back of this �orm. By requesling ihe rebate check be made <br /> payable to the vendor, I agree to the follo�vinq. <br /> 1. I will not receive a rebate check directly from the City of Everett. <br /> 2. Assigning payment oi the rehate to the vendor does not exempt me irom Back�;�a;er <br /> Prevention Device Re6ate Program requnements. <br /> I aulhorize ti�e release ot my rebatc to the vendor listed on Ihe back o(lhis form pending � <br /> approval of the compleled Backwater Prevention Device rebate packet by the Ciry of Everett i <br /> I <br /> i <br /> ��-tn..� Gu,�r i a/2�// /% <br /> ISignature of Property Ovaner Date <br /> �-- - ---- <br />