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�3ack��r��ter �revention Device Rebate Program <br /> Ve:ndor Payment Option Form <br /> Project Number:_ __ (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ���5 �/ To�/,S�1J <br /> �/ � <br /> Installation Address: Gb�5 /`•�f'_f= . S <br /> Q ! <br /> p'�- i <br /> City: �f✓�a-z Slate:�_Zip: /.O(�� ` <br /> �� � <br /> Mailing Address (if dilferenf): �7_>�S � �jerG, c�.✓ ST <br /> ��/ o, I <br /> City: T��iz-ri��� State: =�� Zip: / 7C�I� <br /> Email: 14��i._ /'In,.�'rc. �� �-/^No::, Con1 Phone: 60�) S`r L �/ 3� � <br /> Tolal Cost to Install Device (from conCractorinvoice): S ` <br /> I,the property ovrner, request to have the City of Everett Backwater Prevention Device rebate check � <br /> for the installation of the device at lhe above referenced property address be made payable to, and � <br /> sent to, the vendor specified on lhe back of this form. By requesting lhe rebate check be made � <br /> payable to the vendor, I agree to the follo�ving: ` <br /> 1. I wiil not receive a rebate check diredly from the Cily of Everelt. <br /> 2. Assigning payment of ihe rebate to the vendor does not exempt me from Backwater <br /> Prevenlion Device Rebate Program requirements. <br /> I <br /> I aulhorize the release of my rebate to the vendor lisled on the back o(this(orm pe��ding <br /> approval of lhe completed Backwater PreventioroDevice rebate packet by the City of Everetl <br /> i <br /> � � � <br /> ' �� I <br /> � <br /> �'=--. �"^ �Z -") - T o;J <br /> � • <br /> f'signature of Properly Owner �ate <br /> I <br />