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Backwater f�reven4ion Device Rebate Prograr.i <br /> �lendor Paymeht Option Form <br /> P,reject Number: _ (Gp' to Pro��ide) <br /> PiedSB Goil�Nieie i7Gii1 SiiieS Oi iile iUrfn <br /> Property Owner 5ection; <br /> PropOrty Ocrnzr N�me �!C'c d.C,I_J—'"i=�1�S-4t�------ - —— :1 - <br /> � I 3[�� �� �'G iJ c, i <br /> Inslalla(ion Add{ess -- � <br /> i city � ve�e-�-_ _ statei . W� z�p R FJ20 1 I I <br /> I /�- i <br /> iA4aii�ng Aotlress (il di'nerenf) _ 5 I ; <br /> i City State: — Z�P --- i <br /> � !� 'L u Z-3-7's Z � <br /> ' Email: Phone: �1� _____ <br /> � G� �`I � s c� _� � <br /> � Total Cost ro Inslall Dev�ce (6om cont�acror ii�voice), S --- <br /> �-- - — ----- ---- � <br /> I the prop=rty ovmer, request to havz fhe City ot Ev2reti Backwater P.revent�on Dev�ce reba�� check � <br /> for Ihe in5alla�ion of Ihe device at tne abuve referenced property address be made payabl2 lo. antl � <br /> sent to. the vendor speci(ied on the back of lhis (orm..By requesi�ng'Ihe r26ale check be made i <br /> pa�able to.the vendor. I ag�ee lo the follo�n��ng. � <br /> 1 I �a�ill not receive a rebate check d�re:lly (rom the Cily of E��eretl <br /> "l. AsSigning payment o( lhe rebate to tha vendor does not exempt �ne fro��� �:�ck�•+ater <br /> Prevention Dewce Rebaie Proorani requiremenls <br /> i— ---_..---- ----_ - ------ -------- — ----- I <br /> � I authorize the release of my rebate lo ihe vendor listed on the back of Iliis (orm pend�ng <br /> i approval of the completed Backv�aier Frevention Device rehate packetby the City o( Everetl <br /> i <br /> ' ,,, � �� �ec.i.� _��i� <br /> -���i_L`�'.—,_p . — , <br /> i Dat <br /> i SignaWre of Frope�y Ovmer — ' <br /> � <br />