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Eiackwater Prevention Device Rebate F'rogram <br /> Ev Vendor Payment Option Form <br /> P�cj�ct Number: --- (Qty fn P�cvid^) <br /> I'IQ�ISC CUII1�)ILII; UUlll JIUCJ UI iiiB i0ii"n <br /> Property Owner Section: <br /> � Property Owner Name: _�ll v,l� �.%�((G� ---- — I <br /> IInslallationAddress _�� (��'«��%ve^u! <br /> I /� <br /> Gry: ������ --. - Slate: �� Zip: "( �/ <br /> I <br /> � :vtalling Address (il dilferentJ. <br /> Cily: _ State: __ Zip: <br /> � t=mail: / /�1!�'`//Q�� GO(. GO^�--- Phone: (�/J���6-�fZ, — <br /> � Tolal Cost lo Install Device (lronr ca�tractor invoiceJ 3_��'f�9 � <br /> I, Rie properiy owner, request to have the City of Everetl Backwater Prevention Device rebate r.heck <br /> for the installation of !he device at lhe above r�:(erenr.eci property address be made payahle ,o, a;�d <br /> senl fo, Ihe vendor specified on the back of th's fo�m !?� requesung the rebate cf��eck be m;�d� <br /> pa;able lo the vendor, I agree to the follo�v�np <br /> 1. I v✓ill not receive a rebate check di�i c11�- fio�n the C„y u( Fven;tt <br /> 2. Assigning payment of the rebale lo Ihe vendor does nol exempt me from 13ack����ter <br /> Preventlon Oevice Rebate Proyram requiremenls. <br /> �-- — ---- -------- --- - I <br /> � I au!iionze the release of my rebate to Ihe vendoi hsted on lhe back of this (orm pendin� <br /> a;pproval of the completed Rack���ate� Prev��nbun flr,vice rebaie packet by ihe City of[veretl <br /> � <br /> /� <br /> � / � � S <br /> S; nalure of Property Oivner Date <br /> .- ----- - _ ----- - _ _ _ - - --- -- - -- --J <br />