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Backwater Prevention Device Rebate Program <br /> Vendor Payment Optic�n Form <br /> Project Number: (Cify to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: �-�'� � );�+.,>F� U�.�S�v, <br /> Installation Address: � b J� ��rr, �u.,� �Vf. <br /> City: �v� State:�_Zip: `��j?.u� <br /> Mailing Address (r(diHerent): P� L3U! IDLy <br /> City: C��•� l�i� State: 1v'4 zip:_ yY2S', <br /> Email: �vhS�ti. �Cu-.+c:�s�1�ncd` __ Phone: (�d, ) S�-SYl4 <br /> Tolal Cost to Install Device (from con(ractor invoice): $ <br /> I, the property owner, request to have lhe City of Everett Backwater Prevenlion Device rebale cheek <br /> for the instaliation of the device at the above referenced property address be made payable lo, and <br /> sent to, the vendor specified on lhe back o(this form. By requesting the rebate check be made <br /> payable lo lhe vendor, 1 agree lo the following: <br /> 1. I v✓ill not receive a rebale check direclly from the City of Everett. <br /> 2 Assigning payment of Ihe rebale to the vendor does not exempt me from Backwater <br /> Prevention Device Rebale Program requirements. <br /> � I aulhorize the release of my rebate fo the vendor listed on the back o(this form pending 1 <br /> approval of the compleled Backwater Prevention Device rebate packet by the City of Everett <br /> I <br /> � y�L���s I <br /> Signat�n�Prope. er Date i <br /> — --- - ---I <br />