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, i <br /> , Backwater Prevention Device <br /> � Rebate Pc�ogram <br /> � <br /> IFor internal Use: Project Number: <br /> Ve�ndor Payment Option Forrrt <br /> ; Please complete both sides of the form <br /> Property, pwner Section (please print); <br /> � <br /> /� � -------_ <br /> �I-r;n[' JrPI-fc✓ <br /> Property.�Owner Name — <br /> --1-2L� Lo,��d �✓e ��'ue�e�f l,�l�t `�'��7U/ <br /> Property Address <br /> Cily State Zip <br /> Nternate;�Mailing Address Cil <br /> � Y Slate ZiP <br /> �'- 5L-399.3 r-}i"e-I�er o <br /> Phone � � � tY�Q�� � Cc�r <br /> • Email <br /> I, the Propehy Owner, request to have the City of Everett Backwafer Prevention Device <br /> rebate check for ihe 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 ayree to the following: <br /> I <br /> 1. I wiil'not receive a Backwater Prevention Device rehate check directly from the <br /> City of Everett. <br /> 2. Assigning paymenl of the Backwater Prevention Device rebate lo the Vendor <br /> doesi iiot exempf m, irom Backwaler Prevention Devir,e Rebate Program <br /> requirements. <br /> I authorize;the release o( my rebate to the Vendor lisied on page lwo of this form <br /> pendiny aPproval of the completed Bacicwater Prevenann Device rebate package by <br /> thr, Cily of�Everett <br /> C���' �z� is <br /> _�%, ' _ _.�-- <br /> SignaL�re of P�operty Owner <br /> , ' � Date <br /> �� <br /> I <br /> I <br /> I <br /> Revi;r.cl 913!'Lf114 Pnge 1 n;2 <br />