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Backwater Prevention L?evice Rebat� i'rogra�n <br /> Vendor Payment Option Form <br /> Project Number. (City to Provide) <br /> Please r.omplete bath sides of the form <br /> Property Owner Section: <br /> Property Ovmer Name: � �t✓L T�i/ 1�-ev�f F <br /> (nstallation Address���� �6Y1/� �aYG� � <br /> City:��/�bU'� State:�V� Zip: t�� <br /> Mailing Address(i(differenQ: <br /> City: State: Zip: <br /> Email: Phone:�`1—���UZ) <br /> Total Cost to Install �evice((mm conLactorinvoicej:� Z"1 CJ� �' r <br /> I, the property owner, request to have the City of Everelt Backvrater Prevention Device rebate check <br /> for the Instailation of the device at the ahove referenced property address be made payable to,and <br /> senl lo,the vendor specified on the back of ihis form. By requesting the rebate check be made <br /> payable to the vendor, {agree to the following: <br /> 1. I will not reco(ve a rebate check directly irom lhe City of Everett. <br /> 2. Assignlno payment of the rebate to the vendor does not exempt me fiom Back���ater <br /> Prevenlion Device Rebata Program requirements. <br /> I authorize the release of my rebate tn the vendor Iisted on the back of[his fonn pending <br /> approval of the completed Back�vatar P�evention Device reCate packet by(he Ciry of Everett <br /> � � � /`�--y� _—��,5� <br /> Signature of Property Owner Date <br /> � <br />