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Backwater Preventior� Gevice Rebate Program <br />�rr Vendor Payment Option Form <br />Project Numbcr. (Ciry to Provide) <br />Please complete both side:> oi the form <br />Property Owner Secfion: <br />Properly Owner Name: �, <br />! Installation Atldress:.� <br />' City: �2_Q <br />Mailing Address (il dif(erent): _ <br />City: $tale: _ Zip: � <br />EmaiC_�I J a. V � �������(Ehone:� �g��rJ� <br />Total Cost to lnstall Device (lrom contractor invoice): S. �-�7�•�d _____ ___ <br />I, the property ovmer, request to have the City of Everett Backwater Preventian �evice rebate check <br />fof the'Installation of the tlevice at the above �efere'nced property address 6e made payable to, and <br />senl,.to;'the.vendor specified on the back of tfiis form. By requesting the rebate:checkbe made <br />payable to the vendor, I agree to the following <br />L, I will not receive a rebate check direcUy from the City of Everett <br />2. Assi3ning payment of lhe rebate to the vendordoes not exempt me.iror, Backwater <br />Prevention Device Rebale Program reGuirements. ` <br />I aulhorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of lfie cornpleted Backwater Prevenlion Device rebate packet by the City o( Everett <br />i <br />Signaturc o Pr perty + er <br />1 ' �j <br />Date <br />:Y <br />..e��rP" i�t'��e `+� '�C e ''i,��y'y�; ��.._ � y''+�l:r�.•.`"�' . �w�y".,..=�r'V`a'.r'w.' �r.�M'a'wu+. 13-t�' �_ ..� "+yi�!�'y...�wt�.�.+ra �� Y <br />k_���.._ _ _ _ <*.2 � K#3 nry.�.'�[g <br />