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4/' Backwater Prevention Device Rebate Program <br />d Vendor Payment Option Form <br />Project Number: _ _ _ _ (City to Provide) <br />Please complete both sides of the. form <br />Property Owner Section: <br />Property Owner Name: <br />Installation Address: <br />City: C)V Lu (V rj State: W, /t Zip:_ <br />Mailing Addre s (if different): <br />City: State: Zip: <br />Email: Phone: (y9 aq3—� <br />Total Cost to Install Device (from contractor invoice): $ A ( o , ob <br />I, 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 following: <br />1. I 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 />I 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 of Properly Owner Date <br />