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� Backwater Prevention �Devi�ce <br /> d � F�ebate Program � <br /> For internal Use: Project Number: _ _ <br /> \oendor Payment Option Form <br /> Flease complete both sides of the form � <br /> Property Owner Section (please print): i <br /> ---- - � <br /> I <br /> Property Owner Name <br /> --- --`� ��l���Y y �l�a s�� <br /> ?roperty Address ( City 5 ate Zip <br /> �. e2r, _v�( � VPy'e� �M^ . Ol <br /> � <br /> \Itemate Mailing Address City State Zip I <br /> '1-G� � <br /> �Rn�•�h���St S �, �,.�ho�,�� ��t , 9���� 3 <br /> L Phone ���` �3,� �3��/ Email � <br /> __ � <br /> , <br /> I, the Property Owner, request to have the City of Everett Backwate� R�e��ention Device ! <br /> rebate check for the installat�on referenced at the Property Address be made pay�b!P � <br /> to, and se,ii to, ihe Vendor. By requesting the incentive/rebate check be made payable <br /> to the Vendor, I agree to the following: <br /> 1. I will not reccive a Backwater Prevention Device rebate check directly from lhe <br /> City of Everett. <br /> 2 Assigning payment oi the 3ackv�ater Prevention Device rebate to the Vendor <br /> does noi exempt me irom Back�+�ater Prevention Device Rebate Program j <br /> requirements. � <br /> �� I <br /> I authorize the release oF my rebate to the Ventlor listed on page two of ihis form � <br /> pending approval of lhe completed Backwater Prevsntion Device rebate par,kage by ; <br /> the Ciry of Everett � <br /> � <br /> , <br /> ` <br /> � ��1ki0.c'��-- -- l _ l'� -�S -- <br /> .��e of Property O�vner Date <br /> Pape 1 or z <br /> Revised 9/3/'J014 <br />