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� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Pro;ect Numbcr __ (City to Prov��ie) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vner Name: 1 ��7'T' /�_ r✓ ii7�L- � S'7'e ���12- <br />Instaliation Address� � �O l7 �9 �!-}�..1� ��li�L'% <br />City L_ l�t'�7�'�f �} _ state: 4Jh'1- ziP •��� �aS�LO� <br />L'ailing Addiess (rl dilferent): �� Z� f� G�t �� s� <br />City: -�C p �'r / �= __ Stat?: �_ Zip: �� � �� <br />Email: � o . � �l��Fir� [' ���( U� Phone. ( ����J�� yy % <br />Total Cosl to Install Device (Irom contracrorinv�ice). $ ,c „%O, / <br />I, the property ov:ner, iequesl to have ihe Cdy of Everett Backwater PrevenUen Device rebate chec's <br />for the inslallation of the device al lhe above referenced property adAress be made payable to, and <br />sent to, Ihe vendor specified on the 6ack o( this form. By requesting Ihe rebale check be made <br />payable to Ihe vendor, I agrec to 1he following. <br />1. I will not receive a rebat^ r,heck directiy irom the City of Everett. <br />2. A;,igning payiaent o1 the rebale la the vendar docs not exempl me Irom Backwater <br />Prevention Device Rebate Program requiremenls. <br />I outhorize �he relcase of my rebate lo Ihe vendoi lisled on ihe back ol this form pending <br />approval of Ihe compleled �ackwater Prevention Device rzbate packet by the Cdy of Everelt <br />-1�'t� � <br />d � � <br />Signal re ot Property Ov:ner <br />z/ 5 <br />Date <br />