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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Numhec (City fo Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: f�✓G �'O r.u�/f <br /> Inslallalion Address: �_������r Sr __ — _ <br /> City: �ve�c!f State: w� Zip���-G/ <br /> ati <br /> h4ailing Address (i(di(ferent): �GS �� ST N�= <br /> City: /f/��en State: �v R _Zip: � ��� <br /> Email: Phone: (3� _GSe�--.3G��_ <br /> Total Cosl to Install Device (from cont�actorinvoice): 5 _�f_so�. ��. <br /> I, lhe property owner, requesl�o have Ite City of E�erelt Back�valer Prevention Device rebale check <br /> (or the inelallation of the device al Ihe above referenced property address be made payable to, and <br /> sent lo, the ve,idor specified on the back ot this torm. By requesting the rebate check be made <br /> payable to �he vendor, 1 agree to lhe (ollo�ving: <br /> 1 I will not receive a rebate check direr.tly from the City of Everett. <br /> 2 Assigning paymenl o(the rebate to the vendor does not exempl me from Backwater <br /> Prevention Device Rebale Program requiremenls. <br /> I aulhorize the rcleasv of my rebate to Uie vendor lisled on the back of lhis fonn pending <br /> approval ol Uie compleled Back�vater Prevenlion Device rebate packet by lhe Cily of Everett <br /> i�a.� �.�,�J�- . �,� . a� _ , y - <br /> Signature of Property Owner Date <br />