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� � ' B�ckwater Prevention Device <br /> � � Reba�e Program <br /> � For internal Use: Project � �.m6er. <br /> I - __ <br /> Ve��ndor Pay�ment Option Form <br /> Please complete both sides of the form <br /> i I <br /> Praperty Owner �ection (please print): � <br /> I <br /> � � --- — <br /> _! _ �2� R,-�-� <br /> ; _ <br /> (Prop`erty'�Oivne�N-am`e� <br /> -,- �-�-;e�S --L��o��,� n��� ��.��,n���i� �g� � <br /> Propert "Address - -+ — <br /> C_-;y, _._� LCity} iState (�_� <br /> Alt�ernate'Mailing'Address ;City� State 2i ' <br /> ._,_ _ _ . _. <br /> _._ `_p; <br /> -�Ph�one C.�Z� •-Zi Z--[�G�(,�tFniaili i <br /> Jr i.�.. �I <br /> � - <br /> I <br /> f, thelProperty Owner, request to have the City of Everett Backwater Prevention Device <br /> rehate check for the installation referenced at the Property Address be made payable <br /> to, and sent 1q the Vendor. By requesting the incentive/rebate check be made payable <br /> to the'Vendor, I agree to lhe following: <br /> t i I will not receive a E3ackwater Prevention Uevice rebale check directly from the <br /> City of f_verell. <br /> �' Assigning payment of the Backwater Prevention Device re6ate to the Vendor <br /> does not exempt me from Bar.kwater Prevention Device Rebate Program <br /> � requiremenls. <br /> i <br /> I aulhorize Ihc rclease of my rebate to the Ve�dor lisled on page two of this form <br /> pend,ing approval of the cumpleted F3ackwaler Prevention �evice rebate packaye by <br /> the C�,�ity of f-veretl <br /> I �_��s%=�� l2. ^lS <br /> ` I �_.: _ <br /> �. ra — <br /> CSi nature of Prop`erty pivner, <br /> �� - -•�_. _.. __ �I �tA� <br /> . � <br /> � ^ <br /> Revised:91312014 Page 1 of 2 <br /> i <br />