Laserfiche WebLink
� <br />� <br />Backwater Prevention Device <br />Rebate Program <br />For internal Use: f^oject Number. _ <br />Vendor Paym�nt Option Forrri <br />Please comple2e both sides of the forrn <br />Property Owner Section (please print): <br />----�a�� � 3_r-� _t — <br />Property Owner Name <br />`�-_i�3 I..FJ��!/2D l)2 E�RrnZT W�I— ��w � <br />Property Address City State Zip , <br />Alternate Mailmg Address <br />Ph�r.� <br />State Zip <br />m <br />I, the Property O�^mer, request to have the City of Everett Backwater Prevention Device <br />rebate check for the inst211ation referenced at the Property Address be made payable <br />to, and sent to, the Vendor. By requesting the incentivelrebate check be made payable <br />to the Vendur, I agree to lhe following. <br />1. I wili rot receive a[3ackwater Prevention Devir.e reh�te check direclly from ihe <br />City of Everett. <br />?_ �\ssigning payment of the Rackwater Prevention Device rebate lo the Vendor <br />does not exempl mu ironi f3ack�'rater I'ievr;ntion Device Rebate Program <br />requirc:ments. <br />I authorize the rclease o( my rebate to the Vendor list�d on page Iwo o( ihis form <br />pendiny appr�val of the completed Backt�rater f'revention Device rebate package by <br />tlie Cily of Everett <br />--�/�t /�n.�� <br />Signature l �`�'���perty Owner " <br />Ho�ris^.d 91�?'_01:: <br />3�-y-�', <br />P„a�� 1 of 2 <br />