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Backwater Prevention Device <br /> � - R:ebate Progra�n <br /> For internal Use: Projecl Number: <br /> Vendor Payment Option Form <br /> Please complete both sides of the form <br /> Property Owner Section (please print): <br /> —L�^�r � $ � <br /> Property Ov er Name <br /> i�30 l.o��.,h�cl_� t�� �,,� ��-�— L-�� �512Z� t <br /> Propeily Address City State Zip <br /> Alternate fNailing Address City State Zip <br /> �-(ZS—2Sq-Z'l Scv <br /> Phone Email <br /> I, the Property Ov�mer, request !o ha�e the City oi Everett Backwater Prevenlion Device <br /> rebate check for the installation 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 wili nol receive a Backvdater Prevention Device rebate check directly from the <br /> Cily of Everett. <br /> 2. Assiyning payment o(the Backwater Prevention Device rebate to the Vendor <br /> does not exempt me from (3ackwater Prevention Device Rebate Program <br /> requiremenls. <br /> I authorize the release o(my rebate to the Vendor listed on page two of this (orm <br /> pending approval of the completed E3ack�vater Frevention Device rebate package by <br /> the City of Everett <br /> -`�-E��`�/_' �-� — 2�z/�S — - <br /> J Siynature of Property Owner Date <br /> Page 1 of 2 <br /> Revised 9/3/2014 <br />