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Backwater Prevention Device Rebate Program <br />Vendor Payment Option For�m <br />Project Number: __ __ (City lo Provida) <br />Please compfete both sides of the form <br />Properry Owner Section: <br />Property Ov:ner Name. ����D ��'' "���� <br />Installation Addr��ss� 2��7' ���A� �'� <br />City: C���/' State:_�vr� ___ __.Zip: J�a�P%� <br />Mailing Address (if diHerent,�: 5���' �` <br />City: <br />f State: f�_ ZiP�— <br />Email: W�n%� �C� �i�1��G . L�D� Phone: ��'����— <br />Total Cost to Install Device (from contractor invoice): S��I �� <br />I, Uie property owner, request lo have the City of Everett Dackwater Prevenlion Device rebate check <br />for the installation oE the device at the above referenced property address be made payable to, and <br />;enf ro. the vendor specified on the back of this torm. By requesting the rebate check be made <br />pa; �Mc lo �he vendor, I agree to the follotiving <br />1 I will not receive a rebate check directly from the City of Everett. <br />7. Assigning payment of lhe rebate to lhe vendor does not exempt me from Dackwater <br />Prevention Devire Rebale Program requirements. <br />I authonze the release of my �'ebate to the vendor lisled on Ihe tack of this iorm pending <br />approval of the compleled Backwater Pre��ntion Device rebat�_ packet by the Ciry of Everelt <br />� %w �j')? �,rv�,G�r_Jz�I <br />CT— <br />Signature of Prooerty O�vner <br />/!� ! /.5 <br />Date <br />_.I <br />