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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Number: (City to ProvideJ <br />Please complete both sides of tlie form <br />Property Owner Section: <br />Properly Oaner Name: <br />' i \i , 1 <br />' � � �Q • ' • • � <br />Mailing Address (ildiHerent): <br />Totai Cost to Install Device (Irom confractor invoiceJ: � ri��T �� • �� <br />I, the property owner, request to have the City of E��erett Backwater Preveniion Device rebate check <br />for the instailation of the device at the above referenced property address be made payable to, and <br />sent to, Qie vendor specified on the back of this torrn. By requesting the rebate check be made <br />payable lo Ihe vendor, I agree to the following: <br />1. I will not receive a rebate check direc0y from lhe City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwaler <br />Prevention Device Rebale Program requirements. <br />I authorize the release of my rebate lo lhe vendor lisled on the back of this form pending <br />approval of the completed Backwater Prevenlion Device rebate packet by the City of Everett <br />� ' ' �-��-� S <br />Signature of Pr perty Owner Date <br />