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Backwater Preventi�n Device Rebate Program <br />Vendor Payrnent Option Form <br />Prc�ecl Numbcr __ iC;ty to P�ovide) <br />Please complete both sides o4 the form <br />Prc�perty Owner Section: <br />---- — — - -------- — - - ----- <br />� �1_N_C.� �T�1� - � <br />Property O�vner Name: — __ _ <br />Installation Address L�Q�( J�'V��YL ___ <br />iCiiY: �� ��j 1 L— _ Sl'ate: %V P _ Zip: ��L�/ � <br />; 1,1ai6ng Address (d dJ/erenfJ: Z7 ��`t-Y"'V �V � • _ <br />Gty _C�U�'7`� ` � Slate. �A Zip: G� �J�✓L <br />Emai� ILMi]T��I� � "�►• GD��_ Phone: (�-Z� �� ��J� <br />Total Cosl to Install Device ((rom contractor invoice): 5 oL��3 (��� <br />I, the p�operty o�vner, requesl to have the City of Everett Back�.vater Prevention Device rebate check <br />(or the instailation of the device at Ihe above referenced propeAy address be made payable lo, and <br />sent to, the vendor specified on ihe back of lhis form. By reyuesliny Ihe rebate check be made <br />payabie to the vendor, I agree to the following� <br />i I�vill not recerve a rebale check direc0y from Ihe Cdy of Everell <br />Z. Assigning payment o( lhe rebatc to lhe vendor does nol exempl oie frorn Backwater <br />Prevenhon Device Rebale Progiam requiremenls. <br />I authonze the release o( my rebate to the vendor listed on lhe back ol this form pending <br />approval of the comple��d Backwater Prevenlion Device rebate packet by lhe Cily ol Everetl <br />•� .(/,,, �Z/L .- �-�L��� — <br />Signature of Properly Owner <br />/ — � —/.S`_ <br />�ate <br />