Laserfiche WebLink
� <br />Backwater Prevention Device <br />Rebate Program <br />For intemal Use: Project Number: <br />Vendor Payment Qption Form <br />Please complete both sides of the form <br />Prope►ty Owne • Se�tion (please print): <br />ProperryOwnerName 3vi3 �o���� <br />�, •E'u c�- • f-•{- W A �T 6�.�— <br />Property Address I City S�ate Zip <br />��A�l�no,��'�S�L�IGI�oJ.cvw, 7_RO� t`��f�` Slreal— <re��'�{-����}�`i� <br />Aiternate Mailing Address City State Zip <br />u7_5=3�l6—(,i�� <br />Phone Emafi <br />I, the Property Owner, request to have the City of Everett Backwater Prevention Device <br />rebate check for the installation referenced at the Property Address be made payabie <br />to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br />to the Vendor, I ac�ree to the following: <br />1. I will not receive a Backwater Prevention Device rebate check directly from the <br />City of Everett. <br />2. Assigning payment of the Backwater Preyention Device rebate to the Vendor <br />does not exempt me from Backwater Prevention Device Rebate Program <br />requirements. <br />I authorize the release of my rehate to the Vendcr listed on pape two of this form <br />pending approval of the completed B,�ckwater Prevention Device rebate package by <br />the City of Everett <br />0./%/% a� �1� <br />Signature of Properfy Owner <br />a�1- �o, z�,��� <br />Date <br />Page 1 of 2 <br />Revised 91312014 <br />