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4 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 />Proparty Owner Name: P> 7—eA— fy�ss <br />Installation Address: %/ l-/OY AVE- <br />City: C--VCkL7F— State: W r} Zip: n! ) <br />Mailing Address (if different): SR n~2^ <br />City: _ State: Zip: <br />Email: Phone: (04-) <br />Total Cost to Install Device (from contractor invoice): $ <br />I, the property owner, request to have the.City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />i. I will not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Ret.ate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />Signature of Property Owner <br />"/ <br />Date <br />