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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Numt:er. _ (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: I kI ct' /� <br />Installation Address: Z�-(j�."L0_A_' I _D 610201 <br />� <br />City: I�L1aA --_ State: Wzip: " I 0 201 _ <br />Mailing Address (if different): <br />City: <br />State: <br />Email: y • coo Phon�(e: { 6 (o 10 -4ro677 <br />Total Cost to Install Device (from contractor invoice): $ r� `f: M " o <br />I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />I will not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />Signature of Property Owner Dale <br />