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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Number: _ (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: � i✓i -� � SJ �n.� ✓ <br />Installation Address: _k�,r -7� ✓u�C� l9 � <br />City: �� ✓fi' F Stale: (iv El Zip: � ri Z G � _ <br />tvlailing l�ddress (i(diNerent): <br />City: <br />EmaiC <br />State: <br />Phone:F12� 3z'� •lu37 <br />Tolal Cost to Inslall Device (fiorn contractorinvoice): 5 2,'1�iS. Z 2 <br />I, the property ovmer, request to have the City of Fvereff Backwater Prevention Device rebate check <br />for the installation of lhe device at the above referenced property address be made payable to, and <br />sent to, the vendor tiper.ified on ihe bar.k of this (orm. 6y requeslinc� the rebate check be made <br />payal�le to the vendor, i agree to the following: <br />1 I will not receive a rebate r.heck direclly irom the City of Everelt. <br />2 Assignin9 peyment of the rebatc to lhe vendor does not exempt me irom Backwater <br />Prevenliun Device Rebate Program requiremenls. <br />I authorize ihe reiease of my rebatc to the vendor lislcd on lhe bach of lhis fonn pending <br />approval of the completed Backwater Prevenlion Device rebate p�cket hy the City of Everett <br />-��� �,,� --- �-a�',��is <br />Signature oi Property Ovmer Dale <br />