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Backwater Prevention D�vice Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (City:o Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property.Ownar Name��''�A��1 �P �,�i�, ��`�����'a ��`� <br /> � � J,.� � � <br /> InstallationAddress� �6'.�� � n1�Z�� <br /> City: Q�S� State: 1.�� Zip: � r�` ��C�l <br /> Mailing Address (i(diHerent): <br /> Cily: Slate: Zip: <br /> Email: Phone: ( ) <br /> Total Cost•to Install Device (from contracfor invoice): 5_�,.[�-� <br /> I, lhe property owner, request to have the Cily of Everetl Backwater Prevention Device rebate check <br /> for the installation of the device at the above referenced property address be made payable lo, and <br /> sent to, the vendor specified on the back of this form. By requesting.lhe rebate check be made <br /> payable to the vendor, I agree lo the�ollowing� <br /> 1. I will not receive a rebate check direcUy (rom the City of Everetl. <br /> 2. Assigning payment o(Ihe rebate to the vendor does not exempt me from Dackwater <br /> Prevention Device Rebale•Program requirements. <br /> I authorize the release of my rebate to the vendor listed on the back o(this form pending <br /> approval of lhe completed Backwaler Prevenlion Device rebale packet by ihe City of Everett <br /> ��— <br /> Signature o(Property Owner Date <br />