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44Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form r <br />Project Number. (City to Provide) <br />(lll'`1 <br />'AN �D <br />Please complete both sides of the form t'( fB �6 7015 l� <br />I C' W pRxs <br />Property Owner Section: <br />Property Owner Name: �1 U0? 'e 0,117 <br />_ <br />Installation Address: 7 7! S" 7nr' <br />City: 2�Urr P J r State: &i ✓—I( Zip. 2 'q 2 n i <br />Mailing Address (if different): /). q,01 fi t� Al b <br />City: S PU TT/e,State: (i/A Zip: C 0 /2 -S <br />Email: Phone: ?-O') 3(, c1-1 0 9 <br />Total Cost to Install Device (from contractor invoice): $ <br />_J <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 b? 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 />t. 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 <br />Date <br />