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Backwater Prevention Device Rebate Progr3m <br />Vendor Payment Option Form <br />Project Number: (Crty to Provide) <br />Please compiete both sides of the forna <br />Property Owner Section: <br />Propeiry Owner Name: � 1 �ib�� �'��1� <br />Installation Address: Q � �) ("'T2.� �� <br />^ �6 ✓� <br />Ciry: �4,'t/1�i� State: �— Zip: <br />Mailing Address (if dil(eren!): <br />City: State: _ Zip:_ <br />Email: Phone: ( ) <br />Total Cost to Instail Device (/rom cnnfractorinvoice) 5 �3c1���- <br />I, the property owner, requesl to have the Ciry oi Everett Backwater Prevention Device rebate check <br />for the installation of the device et the above reterenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting fhe rebate check be made <br />payable to the vendor, I agree to the foliowing' <br />1 I�vili not receive a rebate check directly from the City of Everett. <br />2 Assigning payment of the rebate to the vendor does not exempt me 1rom Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back ot this form pending <br />approval of the completed 8ackwater Prevention Device rebate packet by the City of Everett <br />c� <br />-�F�'�=�� `�--� -�--_ `��. <br />Signature ol PropeRy Owne� Date <br />