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4dBackwater Prevention Device Rebate Program <br />£>r Vendor Payment Option Form <br />Project Number: _ _ (City to Provide) <br />Please complete both sides of the form <br />Property Owner Ger..tion: <br />Property Owner Name: <br />Installation Address: -y�L� Y r VC <br />n <br />City: r�[�K"( 'State: A- Zip: 7,D <br />Mailing Address (i(different): C`4'-C <br />city: <br />State: <br />Email: Phone: ( ) <br />i <br />Total Cost to Install Device (from contractor invoice): $ <br />I, the property ov.ner, 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 />1. 1 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 Rebate Program requirements. <br />1 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 Property Owner Date <br />