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Backwate� Prevention Device <br />Rebate Program <br />For intcrnal Use: Project Number <br />Vendor Payment ORtion Form <br />Please complete both sides of the form <br />Property Lwner Section (please print}: <br />GZ-P,�L ` <br />Property O,vner Namo <br />a�a <br />Propeity Address <br />City State Zip <br />�r� <br />Altemafe Wiailing Address City State Zip <br />Y Z�. zlsr• 7�09 �es ,�r ic ,Lew�;r o y0L �� <br />Fhone Email <br />I, the Property Owner, requesl to have the Cily of Everett Backwater Prevenlion Device <br />rebate check for the installation referenr,r;d at the Property Address be made payable <br />lo, and sent to, the Vendor. [3y requesting the incentivelrebate check be made payab!e <br />to the Vendor, I agre:e to the following: <br />1. I will nnf receive a Backwater Prevention Device rebate check directty from the <br />Cily of Everett. <br />2. Assiyniny paymenl of the Backwater Prevention Device rebate to the Vendor <br />does not exempt mo from Bar.kwater Prevention Device Rebale Program <br />requirements. <br />I authorize the release of my rebate to thc Vendor listed on page two of ihis furm <br />pending appruval of the compleled dackwater f�ir,vention Devia: rebate package by <br />the City of Fverett <br />L <br />-_. \/ �� __- <br />Siynature of Properiy U�vner <br />--�/ ��— <br />Date <br />Revi.Sr,d fl/;s/)ptq F'age 1 nf 2 <br />