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. i <br /> �� <br /> . G Backwater Preve;ntican �evice <br /> 'F���� Rebate Program <br /> i <br /> For internal Use: Pr'ject Number: <br /> Vendor Payment Option Form� <br /> Please complete both sides of the form <br /> Property Owner Section (please print): I <br /> ; <br /> � <br /> �1�,�.�„ -�. `�`�✓�� °�h�u ��a��1st w <br /> Property Owner Name � <br /> __'�o�-'-� V,v�v��l �\�f� l��v,t�- I W�� I�Z_ol <br /> �-�...._.. _ <br /> P�operty Address City–;1�1 ; Slate� iZip�-��r <br /> h7"�� L'lViy�Y.` t\�Sl Cv�7Vx11 � �Vr� I�� (1+� <br /> SAlter�^nate.�viailing'Adilress City7 i Sta'te� Zf� <br /> (S<<Z 4��i-�`..�� ��--�,.'�3 �.����.:.;I.c�.-, <br /> 'Phone—° �Email-�� ; <br /> i <br /> i <br /> I, the Property Owner, request to have the City of Everett Backwater Prevention Device <br /> rebate check for lhe installation referenced at the Property Address be made payabie <br /> to, and sent to, lhe Vendor. By requesling the incentive/rebale check be made payabie <br /> to the Vendor, I agree to the following: � <br /> 1 i vdill not receive a f3ackwater Prevention Device rebate �heck directly from (he <br /> City of EveretL � <br /> 2. Assigning payment of the F3ackwater Prevenlion�Device rebate to the Vendor <br /> does not exempt me from Backwater Preventio�i Device Rebate Program <br /> requirements. ; <br /> � � <br /> I authorize the release of my rebate to the Vendor list�d on pa�e hvo of this form <br /> pendiny approval of ihe completed Backwater Prevention Uevice rebate pacl<ac�e by <br /> the City of Everett i <br /> / � i <br /> �� ,r.;,�L.��_,��.._. � 3� t5 <br /> ✓ ; <br /> Signature o rop`erly OT v✓ner � U cat � <br /> � <br /> i <br /> � Page 1 of 2 <br /> Revised 913/2014 i <br />