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� <br />� <br />Backw�ater Prevention Device <br />Rebate Program <br />For internal Use: Project Number: <br />Vendor Payment Option Form <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />Property Owner Name <br />roperty <br />Alternate Mailing Address <br />Phonei.�,� — ��D—�� <br />City <br />Email: <br />State <br />State Zip <br />1, the Property Owner, request to have the City of Everett Backwater Prevention Device <br />rebat�: check tor the installation referenced at the Property Address be made payable to, <br />and sent to, the Vendor. By requesting the incentivelrebate check be made payable to the <br />Vendor, I agree to the following: <br />1. I will not receive a Backwater Prevention Devi ;e rebate check directly from the <br />City of Everetl. <br />2. Assigning payment of the Backwater Prevention Device rebate to the Vendor <br />does not exempl me from Backwater Prevention Device Rebate Program <br />requirements. <br />I authorize the release o( my rebate to the Vendor listed on page tevo of this form pending <br />approval of the completed Backwater Prevention Device rebate package by the City o( <br />Evere <br />_ Gt��{1�� 3 3 1S -- <br />�� Signawre of Property Owner <br />Revised 9/3f2014 <br />, <br />lDate <br />Page t of 2 <br />'h <br />