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I <br />Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />?roject Number: _._ - -_ _ (City to Provide) <br />Please complete bcth sides of the form <br />Property owner Section: <br />Property Owner Name: <br />Installation Address: 3 �% 3�ir>L Ar1B <br />city'. li ✓Gr _ Slate: �✓ ZiP:�C�� <br />Meiling Address (if different)' - <br />City: <br />Stale: <br />Email: Phone:' (yam 33tr�/ti' <br />Total Cost to Install Cevice (from contracto-invoice): $ rX l �7�• �� <br />1, 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 follo��,ingi <br />1. I will not receive a rebate check directly from the Cdy 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 />I authorize the release of my rebate to the vendor listed on the back of :nis form pending <br />approval of the completed Backwater Prevention Device rebate packet by the'Cily of Everett <br />I <br />nature of Property Owner Date <br />