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Backwater Prevention Device Ftebate Pro�ram <br /> Vendor Payment Option Form <br /> Project Numbec (Cify(o Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Orvner Name: �U J N /�A1 �U�Se i <br /> Installation Address� 1� �( �� ►"v�� /�e��'�e- <br /> � � t•l.l�- zi ��U l � <br /> Ciry:�V 2K2_�_State: p: <br /> Mailing Address(�ldiKerenQ: 2� L � � � . ��� <br /> City:lr/� J �`e �I State: ��Zip� X �17i <br /> EmaiL O�P�+�� hin•��c��NZ.C(� NI_ Phone: (y�Z�/-�{`�Sb <br /> � —7 ✓ - <br /> 7otal Cosl lo Install Device ((rom contrectorinvorce): S�� SOD -% <br /> I, the property owner, request to have the City of Everetl Backwater Prevention Device rebate check <br /> (or the installation ot the device at the above re(erenced property address be made payable to, and <br /> sent to, the vendor specified on Ihe back oi this form. By requesting the rebate check be made <br /> payable lo the vendor, I agree to the tollowing: <br /> 1. I�vill not receive a rebate check direcdy trom the�ity of Everett. <br /> 2. Assigning payment of the rebate to lhe vendor does not exempl me from Back�vater <br /> PrevenGon Device Rebate Program requiremenls. <br /> I authorize ihe release oF my rebate to the vendor listed on the back of this form pending <br /> appi�val o(Ihe completed E3ackwater Prevention Device rebate packet by the City of Everett <br /> . <br /> Signature of Property Owner Date <br />