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Backwater Prevention Device <br /> Rebate Program <br /> For intemal Use: Project Number: ____...._..__. _ ___ <br /> Vendor Payment Option Form <br /> Please complete both sides of the form <br /> Property Owner Section (please print): <br /> �.�c� !�A-�,Ns�� <br /> Property Owner Name _ ���, <br /> l�� / �us�i i A--�fd' !»d�d'i i` --- <br /> Property Address City Stale Zip <br /> Aiternate Mailing Address � Cily Stale Zip <br /> z5-�39-7z35 <br /> Phone Email <br /> I, the Property Owrer, request to have the Gty oi Everetl Backwater Prevention Devicc: <br /> rebate check for the insiallation referenced al lhe Property Address be made payable <br /> to, and sent to, the Vendor. By requesling the incentive/rebate check be made payable <br /> to the Vendor, I agree to the following: <br /> 1. I will not receive a Backwater Prevention Device rebate check direclly frum ihe <br /> City oi Everett. <br /> 2. Assigning payment of the Backwater Prevenlion Device rebate lo the Vendor <br /> does not exempl me From Backwaler Prevention Uevice Rebate Program <br /> requiremems. <br /> I authorize the release o( my rebate to the Vcndor listed on pac�e two of this form <br /> pending approval of ihe completed Backwater Prevenlion Device rebate package by <br /> the City o( Everett <br /> - � — - 07�oi��o�s <br /> Siqnafure o Prope�ly Ovmer nare <br /> ��y� � or z <br /> R��c;��i��3�zori <br />