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Backwater Prevention Device <br /> Rebate Program <br /> For internal Use: Projecf Numbcr. <br /> Vendor Payment Option Form <br /> Pleasc complete both sides of the form <br /> Property Owner Section (please print): <br /> � - ------ <br /> ��c.� bA-Q i N.51� � ___------ - �—Q-- <br /> PropertY���ef �i.�3� l-CG[/�'�.'�• i �1.5T��" Q!S ZBJ <br /> / � <br /> Prope�ty Address Cily State Zip <br /> Allernate Mailing Address r. 'City State Zip <br /> �I zs - 234 -7�35 <br /> Phone [mail <br /> I, the Property Owner, rer,uest to have lhe Cily of Everett Backwater Prevention Device <br /> rebate check for the installation re(erenced at tlie Property Address be made payable <br /> to, and sent to, the Vendor. Ey requesting tfie incentive/rebate clieck be made {�ayable <br /> to the Vendor, I agree to the following: <br /> 1. I will not receive a Backwater Prevention Devicc rehate check direclly from the <br /> City of Everett. <br /> 7_. Assigning payment of the Backwater Prevention Device rebale to thr Vendor <br /> does not exempt me trom Dar.kwater Prevenfion Device Rebate Program <br /> requirements. <br /> I authorize the release o( my rebate to the Vendor listed on page Iwo of this (onn <br /> pending approval of the completed Dacicwaler Prevention Device rebate package by <br /> the City of Fverelt <br /> �� � S/ <br /> — — � -�-- <br /> Signalure ol Properfy wner Dale <br /> Page 1 a12 <br /> Rcviscd 913/7_OI4 <br />