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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> ProJect Num6er: _ (City fo Provide) <br /> Please complete bofh sic;es of the form <br /> f'roperty Owner Section: <br /> � Property Ot•mer Narne: � /�"(L C��('� <br /> InstallationAddress: � �� � l.r��fj'/1/.� /�l��i, <br /> Ci1y: �✓�TT State: 11/f� 2ip:_ ��u�0 ' <br /> Pdalling Address (if dilferenfJ: i1lfJ- <br /> City: State: z�p: <br /> Email: �`l y II ���>Y.'�1.�/L . CO� Phon2� (y/i� 3S 7 - `// US <br /> Tolal Cost lo Install Device (from confraclorinvofceJ: 5 �`���. S`7 <br /> I, the property o:vner, request to have the City of Everett Backwaler Prevention Devlce rehale check <br /> for Ihe Inslallatlon of thr. device al lhe above referenced property address be made payable to, and <br /> senl to, l�e vendor speclfed on the back of Ihis form. Eiy requesting the rebale check be made <br /> payable lo lhe vendor, I agree lo Ihe follotv(ng: <br /> 1. I will not receive a rebate check dlreclly from the City of Everell. <br /> 2. Asslgning paymen!of the rebale to the vendor does nol exempt me (rom 83ckv�ater <br /> Prevenllen Device Rebate Program requirements. <br /> i �uthorizu Iho release of my rebale to lhe vendor Ilsled on the 6ack ot Ihls form pending <br /> approval of the compleled 6ack���aler Prevenllon Device rebate packel by Ihe Cily of 6verett <br /> l�- ��'� 1` " 1- /� _��- <br /> Signalure of roperty Oti�mer Da�e <br /> - - ---- --- - .� <br />