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Backwater Prevention Device Rebate Program <br />Vendor Payment Opt -ion Form <br />Project Number: _ (City to Provide) <br />Please cornplete both sides of the form <br />Property Owner Section: <br />Property Owner Name: ( cVIQ ,f } ���n Ail (g 'F p <br />Installation Address: I (O 12 A I C Q0UQQ `1 At' 4 <br />City: EVP/r-Ef_� State: Oil— Zip:016201 <br />Mailing Address (if different): <br />City: State: Zip: <br />Email,fiy K111Y 5 OEDVWDS lnfF.1�NE7-. FT)l I Phone: (253) 223- $9 is <br />Total Cost to Install Device (from contractor invoice): $ <br />I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. 1 will not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the r=bate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />Signature of Property Owner <br />j ►S <br />Date <br />