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OLBackwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: <br />(City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: LDS <br />Installation Address: / % [ n 2 4 <br />City: t2 J 2 1 % - state:: _Zip: <br />Ma;ling Address (if different): , 0�t -7l.J <br />City: J�e%� State: G}Uzip: % (� / <br />Email: ��_Li�Q S CAiI�I/1��� 1pU1t.NP one: <br />Total Cost to Install Device( mcontractor invoice): $ <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 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 following: <br />1. 1 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 Date <br />