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� <br />Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. _ (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />(�.--�c� n�e S <br />InstallationAddress:_ '/�� � /'Qna <br />I <br />City: �d�P� � State: (��i""- <br />z�p:��/— /3a/ <br />Mailing Address (ildiNerent): S a h7 �—� <br />City: _ Slate: Zip: <br />Email: Phone: ( ) <br />Tolal Cost to Inslall Device (from contrector invoice): $ �'�� �� ��— <br />. 1 <br />I, the property ovmer, requesl to have ihe City o( Everett 8ackrialer Preveniion Device rebate check <br />for the installation of the device at the above referenced property address be made payable to, �nd <br />sent to, lhe vendor specified on the back of this form. By requesting the rebale check be made <br />payable io the vendor, I agree to ihe following <br />1. I e�ill not receive a rebate check directly from the City of Everett. <br />2 Assigning payment of the rebate lo Ihe vendor does not exempt me from Backwater <br />Prevention Device Re6ate Program requirements. <br />I authorize ihe release of my rebate to ihe vendor listed on Ihe back of lhis form pending <br />approval of ihe completed Backwater Prevention Device rebate packet by the City o( Everett <br />/'!— <br />�--�.���� .�--�- <br />` Si ature of Property Owner <br />�- <br />Date <br />