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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: (City to Provide) <br />__ Please complete.both sides ofthe.form <br />Property Owner Sectfon: <br />PropeAy Owner Name: A� • �r <br />InstallationAddress: �}(`�13 l�-�P-� (�i�-� <br />City: �nM-n'it� — State: � Zip: �i��%� <br />Mailing Address (if diflerent): <br />City: <br />State: <br />Email: �7 v�/� Q��/�1� CDY�" Phone: (Ydo'j -r-/��'�� <br />Total Cost lo Inslall Device (/rom confractorinvoice): $ <br />I, the property owner, request lo have the Cily of Everett 8ackwaler Prevention Device rebate check <br />for the installation ot lhe dev'ice at the above referenced property address be made payable to, and <br />sent to, the vendor specitied on the back o( this form. By requesting the rebate check he made <br />payable to the vendor, I agree to the toilowing: <br />1. I wiil not receive a rebale check directly from the City of Everett. <br />2. Assigning payment o( the rebate lo lhe vendor does not exempt me from Backwater <br />Prevenl`.on Device Rebale Program requirements. <br />I aulhorize the release ot my rebate to lhe vendor listed on the bar,k of this form pending <br />approval of the completed Backwater Prevention Device rebale packet by the City of Everett <br />__� �,C � ' " , <br />Signa[ure of Property Owner <br />ll �l i -.,--�' � _ <br />Date <br />