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� <br />EL'F�TET,r <br />Backw�ter Prevention Devi�e <br />Rebate Progr�m <br />For internal Use: Project Number: <br />V�hclor Payment Option Forrn <br />Please complete both sides of the form <br />Property O�nrner Section (please print): <br />Property Owner Name <br />Praperty Address <br />Altern�de Mailing Address <br />Phil�p o. sm;rk <br />?19 9loyt Avz. <br />�vc�ett, 7NasFiington <br />'-IZ� Z��n,l <br />Ciry State <br />5���►O P�s.��a�.��M <br />I, the Praperty Owner, request to have the City oi Everett Backwater Prevention Device <br />rebate dieck for the installation referenced at the Properly A.ddress be made payable <br />to, and sent to, the Vendor. By requesling the incentive/retate check be made payable <br />to tiie Vendor, I agree to the folloaring: <br />1. I will not receive a Backwater Prevention Devica rebate check directly from the <br />Cii:y of Everett. <br />2. Assiyning payment of the Qackwater Prevention Device rebate to the Vendor <br />does not exempt me from Backwater Prevention Uevice Rebate Program <br />requirements. <br />I authorize the release of my rebate to the Vendor listed on page rivo of this form <br />pending approval of the completed [3ackwater F'revention Device rebate package by <br />the City of Everett <br />Signaiure of Property O�vner. <br />Revised 9/3/20'14 <br />r Date �' <br />Page 1 of 2 <br />