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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Numbec (City fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: �y�+ti�o �� �l /(/t� e �� <br />Installation Address: �`� �� �, a�rCi�-� �x�� <br />City. E�/Y_�Y_-� State: WLL Zip: 9 S'r� o/ <br />Mailing Address (il di(/eronf): <br />City: <br />Sl'ete: <br />Email:�Cr1;a.�+1.ri�y1������i.�.Ler� Phone:(76o) 9/�—Sb�P <br />Total Cost to Install Device (from contractorinvoice): 5���if��- Z� _ <br />I, the properly owner, request to have Ihe City of Everett Backwater Prevention Device rebate check <br />for the installalion ot the device at the above referenced property address be made payable to, and <br />sent to, the vendor speci(ied on the back of ihis farm. By requesting the rebate check be made <br />payable to the vendor, I agree to lhe follo�ving' <br />1. I will not receive a rebate check direcUy from lhe Cily of Everett. <br />2. Assigniny payment of lhe rebale lo the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program reyuiremenls. <br />I authorize thc release of my rebate to Uie vendor listed on the back o( this form pending <br />approval of ihe completed Backwater Prevenlion Device rebate packet by the City of Everett <br />�//��j' %%� � ��' <br />%d� <br />�j , <br />Signature ot Property Owner <br />_ �' ���5 <br />Date <br />