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� <br />� <br />�� <br />Eackwater Prevention Device <br />Rebate Prograr� <br />For intemal Use: Project Nwnber. <br />Vendor Payment Option Form <br />Please complete botli sides of the form <br />Property Cwner Section (please prinf): <br />d� �Sl�� , ���. <br />ner Name �!� <br />c'Ni�11-� .i%r��J�. , �Uei'CI l <br />Properfy Address City State 7ip <br />7/� /��,�«���,,.�__ _��� `� e�_ _ �� ��d i <br />Altemate Pdailing Address City S,ate Zip <br />�f2,s- -ds9-�//7 �je r� y(� � sl�i Ql�r, Co�,,,i <br />Phone Email <br />I, IIIP. Pf0(7P.f�;� Owner, reyuest to have the City of Everett Backwater Prevention Device <br />rebate check (or the installation referenced at lhe Prop�rty Address be made payable <br />to, and sent to, the Vendor 6y requesting the incenlive/rebate check be made payahle <br />t� the Vendor, I agree to the following: <br />1. I vdill not receive a Bar,kwater Prevention Device rehate check directly from the <br />City oi Everett. <br />2!� ;si�ning payment of lhe Qackwater Prevention Device rebate to ih� Vendor <br />�Ines not exempt me from Backwater Prevenlion Device Rebate Program <br />requirements. <br />I autliorize the release o( my rebate lo the Vendor listed on page two o( this form <br />pendiny approval of the cornpleled Backwater Prevcntion Device rebate packagc by <br />the Cily o( Everett <br />/ ��%U�7u� t,�.1' /�(�i����Fivr' <br />%'_l.Lt71/ �l� '��%.�.� / .— — <br />j f._ <br />( Signaturen(P�oprri}' wner <br />� ���5'���1/�� <br />D�fc <br />