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�^%^� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />f'ro�?ct ��l�.unGcr __ lCity to Prav;rf^) <br />Please complete both sides oi tlie form <br />Property Owner Section: <br />, /1 <br />� Property Ovmer �dame �, /l %-,� <br />_` U <br />Installalion Address� , �' _Y Q.� <br />r <br />City �f.f r'.:} �'./7- Sta!e. <br />��4ai;ing Adtlress (rl diyerer,Q ___ <br />Gry -- <br />Slatc <br />.i ��lC. Zip� �j/ �O � � <br />C4� <br />Lmai Pnone ( ) <br />' Total Cost Io Instail Device (lrom confractornvoice/: 5 <br />i <br />I. Ihe property owner, request lo have Ihe City of Lverett Backwater Prevention Dev�ce rehate check <br />for the �nstallat�on of the device at the above referenced properry address be made payable to, and <br />sent to, the vendor specd��ed on Ihe b2ck of ih�s (orm By requesting ihe rebale check he made <br />��.3�-ahic to ihe vendor. I agree to Ihe foiloenng <br />t � �vcll no1 rer.ero�e a rebale check directly Gam the C�ty ol [veretl <br />. /�.=signing paymenl of the rebate to the vendor does nnl exempt me from Backv�ater <br />�'�.�ven6on Ucv:ce Re6ale Pwaiam requiremenls <br />I au'h-,nze (hr. release of my rebale lo ;he vendor hsled an the bar,K of this form pendin9 <br />anpioval ot the compleled f�ackv�ater Prevenlion Devir.e iebale packet by Ihe City o1 Evere!t <br />� _ /�/ 'L i� , �� _"_.. _� _�_1s //L� <br />_/1 T <br />I / <br />Signahire o( Pro erly Qwner Uate <br />