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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: (Ciry to P�ovide) <br />Pl4ase complete bo'sti sides of the form <br />Property Owner Section: <br />Property Owner Name: l.(.1,� l/� Ui 1(L�/V„�- <br />Installation Addr ss: J� � r ��LI G��' <br />City: (�/�/1� State: V V� Zip: � L� � 0 � <br />Malling Address (if dillerent): <br />cny: <br />Email: <br />State: <br />Total Cost to Install Oevice (Irom confracforinvoice); S <br />Zip: <br />Phone:( <br />I, the property owner, request to have the City of Everett Backwaler Prevention Device rebate check <br />for the installation of the device at lhe above referenced property address be made payable to, and <br />sent ta, the vendor specified on the back of this fonn. By requesting the rebate check be made <br />payable to the vendor, I agree lo the following: <br />7. I will not receive a rebate check direclly from the City of Everetl. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Badcwater <br />Prevention Device Rebate Program requirements. <br />1 authorize ihe release ol my rebate to the vendor listed on ihe back of this form pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everetl <br />�/U%�/' C„"`'" <br />Signature of Property Owner <br />I �/ I� �0��' <br />Date <br />