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�\%�� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Pro�ect Number. <br />(Gty 10 PloVrdeJ <br />Please complete both sides of !he form <br />Property Owner Section: <br />Iaioperty Owner Name: _ , ` i, .�'. . 1 _, <br />, InslallalionAaaress�. l•.� =. .� ;1��,-�- <br />City - _ � �. � State� Z�p � � �' �' �� � <br />��n�ding Address (rf dillerenfJ: I �� � -• ��� `% � '-�� _ - — — <br />Cily: .� \.,. . . �,. Slale � . .:� _ Zip. � )� - ' <br />Einad. -�c.:.�. i�r..�, . ��.�� �.....� _Phonc+�.U_�1)'il�i �j,..��_ I <br />Total Cost to Install Device ((iom conVacto� m��oiceJ: � � <br />--- --'-- --- ��---- —I <br />i the property nwner, request to have the Cily ol Everelt 8ackwater Prevention Device rebate check <br />for the ��stallation ol lhe devicr at the abnve refer�ncr.A property addrass be made payabt� tu, and <br />sent fo, the ventlor specified on Ihe Uack o( Ihis foirr. �y requesling the rebate checA be matle <br />payablc tu lhe vendor, I agree to Ihe followiny � <br />1 I wlll nol receive a rebale chec� dver.tly (rorn �he Cily ot Everett. <br />2 Assigning paymenl of the rebale to thc ventlor does nol exempl me Irorn Backwaler <br />Prcvention Deoice Rebale Pro�ram requiremenls. <br />� —� � -----� ----- ---- �------- <br />II authonze thc reiease ol my rebate to the vendor listetl on the back ol Ihis (orm pendmg <br />,��;pioe:d nl Ihe complcted Backwater Prevention Device rebile packel by the Cdy ol Eveietl <br />� �---��.;� , 1 <br />i - - r;� G---- -- <br />ISiqnaWrc o(Propchy O�vner <br />I--�-- —� - -- ---- ----- <br />r. l. 2, <br />Datc <br />