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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Number: (City fo Provide) <br />Please complete both sides of•thA form� <br />Property Owner Section: <br />� <br />Properly Owner Name: <br />✓� vR� � <br />I <br />Installalion Address� �ll�l,3 N �w�. S-� ' <br />city: _ r✓e.2ii" state: W%a Zip: �'1/ti�Of <br />Mailing Address (i( dlllerent): <br />City: • State: Zip: <br />Email: M 5� ati ��4�w ��i�o�^ Phone: (�ipy) S9s �vS � <br />Total Cost to Install Device (Irom contrectorinvoicEl: $ <br />1, Ihe property owner, request to have ihe City of Everett Backwaler Prevention Device rebate check <br />for lhe installation nf the device at the above referenced property address be made payable to, and <br />sent to, the vendor speci(ied on ihe back of this torm. By requesting the rebate check be made <br />payable lo the vendor, I agree'to the following: <br />1. I will not receive a rebate check direclly from the City of Everelt. <br />2. Assigning payment ot the rebate to the vendor does not exempt me from eackwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on Ihe back ot this form pending <br />approval of the cornpletod Backwaler Prevenfion Device rebate packel by the Cily of Everett <br />Signature of Property Owner <br />� � � <br />Date <br />