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�ack�vater Prevention Device Rebate Frogram <br />F,r Vendor Payment Option Farm <br />Project Numbe:r. ____._.__ __ (City to Pro�rde) <br />Flea:se compiete both sides of the form <br />f'roperty Owner Section: <br />Property Ovm�r Name: <br />Installa6on Address: <br />City: ���� State: —y v� Zip: { �='-O � <br />Mailing Address (ifdiNerent): <br />City: State: ZiP: <br />Email: V��J I 2�'L�2� N��e i��� Phone: (`J%S) Z52 -�' � <br />Total Cost to Inst�ll Device ((rom contrector invoice): $_ ^%"� %� ' u`� <br />I, the property owner, request to have the City of Fverett Backwater Prevention Device rebate check <br />for ihe inslallation of lhe device at the abeve referenced property address be rtiade payable to, and <br />sent to, the vendor specified on the back oi this form. By requesSng the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. I vrlll not receive a rebafe check direcUy irom the City of Everetl. <br />2. Assigning payment of Ihe rebate to Ihe vendor does not exempt me from f3adcwater <br />Prevenlion Device Rebale Program requirements. <br />I authorize lhc release of my rebale to the vendor listed on the back oF this form pending <br />approval of the completed Backv�ater Prevention Oevice rehate pa�kel by the City of Everett <br />� <br />Signatu e of Pr erty Owner <br />�G ► I <br />Date <br />�. w��.�stt' �;�v_.;. <br />