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Backwater Prevention Device Rebate Prog�am <br />Vendor Payment Option Form <br />Projea Number: _ (c!ry ro Piovrde) <br />Pleaae complete both sides of the torm <br />Property Owne� Section: <br />Property Owner <br />C <br />Instaqallon Address: B �s �SRW-� 1i �1��i <br />City: �V�12 tT�'1- state: W x/. zip: q��-t� I <br />MalNng Address (1/dJf/erant): <br />City: <br />Emaii: <br />State: <br />Zip: <br />Phone:( <br />Tolal Cost to I�stall Device (l�om contrectorinvoice): $,�'�j •� <br />I, the property owner, request to have the City of Everett Badcwater PrevenGon Device rebate check <br />(or the installation of the device at the above referenced property address�be rt�de payable to, and <br />sent to, the vendor specified on the back oi this fomi. Eiy requesting the rebate chedc be made <br />payable to the vendor, I agree to the following: <br />1. I will not receive a rebate check directiy hom ihe City of Everelt. <br />2. Ass�gning payment oi the rebate to the vendor does not exempt me from Backwater <br />Prevention Device kebate Program requiremenls. <br />I authorize the.release of my rebate to the vendor listed on the back of thfs.form pending <br />approval oi the completed Backwater PrevenGon Device rebate packet by the City of EvereQ <br />�!/8?'��� �_ <br />Signature of Property Owner <br />// !G� / � <br />Date <br />