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� Backwater Preventlon Device Rebate Program <br />Vendo� Payment Option Form <br />ProjeclNumber. (CiryroProvide) � <br />Pleass complete both sides of tAe form <br />PropeRy Owner Section: <br />Property Owner Name: J ��, a �� £�5 S <br />Inslaledon Adere6S: � / �% lT � �� /%f>P.0 � . F' <br />c1y: �i r�.i o� state: !.%.F _�v:�/S� a'2 fl� <br />Mr�ny �adress crra�ns�em): <br />City: Slate: ZiD: <br />Emai������.� r� a -'�. �eM P�ane: (yyi�-i R-3Z60 <br />Tail'Go'sl o�nslall Deviee (Irom oonbsaor/nvdce): S��� <br />1, tAe ptpperty owner, request to luve the Clry ol Everett Barkvr�ter Provendon Deviee rebate ehedc <br />fOr tNe In6taltallon 01 Ne devke �t Ihe ebove relerenwd propoAy address be made p�yaDle to, and <br />sent to, the vendor specified on t�e Wck W t�is lorm. By requesting Me �ebale c1�eGc De rtwde <br />payable ro Ihe vmCor. l agree to tha lolbwing: <br />1. I will not rsuive a reba�e check diroclly from lhe Cly of Everntl. <br />2. Asslgnin� paymenl of Ihe reWle la ths vendor doss ool exempl me hom Backwater <br />Prevention Devioe ReDate Proqram requlremenls. <br />I authorize lAe rclease ot my rebate to I�e vendor listed on the back of lhis form perbirg <br />approval of Ihe eompleled Backwater Pnivention Oevice rcbele paekel Ey tne Clty ol Everett <br />p ri <br />Slgnature ol Pmperty Ow�er Date <br />