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i <br /> � B�ckwater Prevention Device Rebat� �'rogram <br /> Vendor Payment Option Form <br /> Project Number. (City to Provide) <br /> I'lease complete both sides of the form <br /> Property (�wner Section: <br /> Propedy Owner Name: _ "' � �`� � <br /> G.� ' 1 <br /> Installation Address: ��yr��n <br /> Ciry: �'GJ12 fu'—t1' State: Zip: ���'��__ <br /> Mailing Address (if different): _ <br /> � <br /> City: State Zip: <br /> ����� � <br /> Email: Phone: ( <br /> — n 3v <br /> Total Cost to Install Device (Irom confractor invoice): �_ 4���`�` <br /> I, the ?roperty owner, request to have•ihe City of Everett Backwater Prevenlion Device rebate check <br /> tor the inslallalion of Ihe device al lhe above referenced property address be made payable to, and <br /> senl to, lhe vendor specified on lhe back of lhis form. By requesling ihe rebate check be made <br /> payable lo�he vendor, I agrec lo lhe following: <br /> 1. I wil�not receive a rebate check direcUy (rom lhe C ty of Everelt. <br /> 2. Assigning payment of the rebale to the vendor does not exempl me from Backwater <br /> Prevrn�ion Device Rebale Proyram reyuiremenls. <br /> I authoriz� �he release of my rebale lo ihe vendor lisled on the back ol this (onn pending I <br /> approval of Ihe completed E3ackwater Prevention Device rebate packet by the Ciry of Eve;ell <br /> — ---- - b I ��. �. <br /> --t <br /> Signalure of Property Owner Dale <br />