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Backwater Prevention �evice Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. _____ (Ciry to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ,J o r�-`�^ C"1 a e n 2.. <br /> Installation Address� I � 2- v �u''''` �' �`'`'��� t�� <br /> Cily: C��-"c'�T Slate:_ i..x4' Zip; 4'{�'c"° '� <br /> Mailing Address (i(differenf): <br /> City: State: Zip: <br /> Email: Phone: (�Z� - 3 s� - Z`� 8 � <br /> 3� <br /> Total Cost to Insiall Device (Irom confractor invoice): S 2 y 8� ' <br /> I, the property ovmer, request lo have the City of Everett Backwaler Prevention Device rebate check <br /> for the installation of the device at the above referenced property address be made payable to, and <br /> sent lo, the vendor speci(ied on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to lhe followiny: <br /> 1. I will no' receive a rebale check directly from the City of Everett. <br /> 2. Assigning payment of the rebate lo the vendor does not exempt me frorn Backwater <br /> Prevention Device Rebate Program requiremenls. <br /> I authorize the release of my rebate to Ihe vendor Iisted on the back of this form pending <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> C��- _.- -�- - 3-id-�-� 5_ <br /> � <br /> Signature of Property Owner Date <br />