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Backwater Pr�evention Device <br /> � R:ebate Prograrr� <br /> For intemal Use: Project Nurnber: _ <br /> Vendor Payment Optian Form <br /> Please complete both sides of the form <br /> Property O��mer Section (plea�e print): <br /> � v��� e��L/�SoN <br /> Property Owner Name � _ <br /> �l a s �-o�ti.�fl�� �4✓�= �,����, W 14 Rgd.o 1 <br /> Property Address City State Zip <br /> � Alternate Iviailing Address City State Zip <br /> < , 5 - 3t�3 -05$S _ � , ,,.�; � so�l� -�'-c-o��"ies. cow� <br /> Phone Email <br /> ` — — <br /> I, the Property Owner, request to have lhe Ci(y of Everett Backwater Prevention Device <br /> rehate check for the installation referenced at the Property Address be made payable <br /> fo, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br /> to lhe Vendor, I agree to the following: <br /> 1 . I will not receive a Backwater Prevention Device rebate check directly from ihe <br /> City of Everett. <br /> 2 Assigning paymenl of the Backwaler Prevention Device rebate to the Vendor <br /> does not exempt me troin Backwater Prevention Device Rebate Program <br /> requirements. <br /> I aulhorize the release of rny rebate to the Vendor listed on page two of this (orm� <br /> pendiny approval oi lhe rompleted Backwater Prevention Device r�batc packaye by <br /> the City of Everett <br /> __� �_— �/l�/�015— <br /> Sign� ture of Property Oi:�ner Date <br /> Page 1 af 2 <br /> Revised 9/3/7_01�7 <br />