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�Backwater Prevention,Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: <br />(C?ty toP�ovide) <br />Rlease complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />Inslallation Address: <br />�1�av� l al�i� <br />S2 <br />�� <br />Cily: �.V2.��1 State: w� Zip: t�fl '_�3 <br />MailingAddress(ildi/lerent): '`"fi �17�l���.� <br />Cily: ��II'�-UUC� State: WO� Zip: Ig��� <br />Email: �I�i ��l a ` ���a ��, �11�'1Gt.i l , �,�w1 Phone: ( ) <br />Total Cost to Inslall Device (from confractor invoice): 5 2, �=� <br />I, the property owner, request to have Ihe City of [veretl E3ackvaater Prevention Device rebate check <br />tor the insfallation of tlig device at the above referenced property aAdrass be made payable to, and <br />sent to, the vendor specified on lhe back o( this form By requesting the rebate check be made <br />payable to the vendor, I, agree to the follov�ing; <br />1. I will not re <br />?. Assigning � <br />Preveitlion <br />a rebate cher,k direclly from the City of Everett. <br />of the rebale to the vendor docs not exempt me from �ackwater <br />Rebalo Prngram requiremenls <br />I authorize Ihe release of my rebate to the vendor lisled on the back of this form pending <br />approval of the completed Backwater Prevention Devir.e rebale packet by the Ciry o( [verett <br />i <br />i <br />/�"ti ( /���'ir';. <br />Signature of Properiy Ovmer <br />�� `���r' -- <br />Date <br />