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Backwater Prevention Device Rebate I�rogram <br />Vendor Payment Opti�on Farm <br />Project Number. (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />Inslallalion Address: l l <br />��-� �V�� <br />c�ry: <br />� <br />l�i z�P: � �� � <br />� <br />Mailing Address (iI diNerent): _ . M� <br />City�_ ---- <br />EmaiC <br />Slate: <br />Total Cost to Install Device (from conlractor invoiceJ: 5 <br />Phone� ( <br />I, the property owner, �equesl 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 follo�ving: <br />1. I will not receive a rebate check directty from the City of Everett. <br />2. Assigning paymenl ol the rebate to Uie vendor does nol exempt me from Backwater <br />Prevention Device Re�ate Program requirements. <br />I authorize the releasc of my rebale lo the vendor listed on ihe back of Ihis form pending <br />approval oi Ihe completed Backwater Preven[ion Device rebale packet by the City of Everett <br />4 <br />� <br />Signature of Property Owner <br />D2 25 1 >' <br />Dale <br />