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. Backvvater Prevention Device <br /> E� Rebate Program <br /> For internal Use: Project Number: ' <br /> l�endar Paymf�r��t O��tion Form <br /> Pleas� cor,iplete both sides of the form <br /> Property Owner Section (plr:ase print): <br /> � c� �=--�T + �DA-N�ri� �A—V I S uN <br /> Property Owner Name <br /> f le 2,'� - 1_U w�.3/a- R-� 2v�'. �.'�/�-',q�"L-T �1.��7�I <br /> Property Address City State Zip <br /> 17� �3�x 1 f �5� - �fiA-c��.✓Ue� , i �,Y'Zcl 2— <br /> Alternate Mailing Address City _ State Zip <br /> c,� Z�- 23�i -S�S�S� �D�a�v� s u�J -�UlA�#l-fz�,J•cae� <br /> Phone Email <br /> I, the Property Owner, request to have the City of Everett Backwater Prevention Device <br /> rebate check for the installatio+�-referenced at the Property Address be made payable <br /> to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable _ <br /> to the Vendor, I agree to the following: - - <br /> 1. I will not receive a Backwater Prevention Device rebate check directly from the <br /> City of Everett. <br /> 2. Assigning payment of the Backwater Prevention Devics rebate to the Vendor <br /> does not exempt me from Backwater Prevention Devic:; Rebate Program <br /> requirements. <br /> I authorize the relea�se °F�tny r�to the Vendor listed on page two of this form <br /> pending approv I-6f tlie co eted Backwater Prevention Device rebate package by <br /> the City of erett <br /> G <br /> /Z—T zo;y <br /> ignatu of Property Owner Date <br /> Revise� 9/3/2U74 �'age 1 0;2 <br />