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Backwater Prevention Device Rebate Program <br />Grr Vendor Payment Option Form <br />Project Number: _ (City to Provide) <br />Please conipieie boi:h sides 0( file 101'171 <br />Property Owner Section: <br />Property Owner Name: 7< Ct r r E . Q it Oct j <br />Installation Address: (I 2 Z <br />City: FIV o' " - " State: <br />Mailing Address (if different): <br />wn ricc /V'e , <br />W/t <br />City: _ State: Zip: <br />Email: kntr( .9uca�' yr.cr/.c�++�Phone: cjGZ-(3YS� <br />Total Cost to Install Device (from contractor invoice): 5 <br />I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor. I agree to the following: <br />I will 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 from Backwater <br />Prevention Device Rebate Program requirements <br />I authorize the release of my rebate to the vendor listed an the back of this form pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />Signature of Property Owner <br />Date <br />