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Backwater Prevention Device Rebate Program <br />00 W Vendor Payment option Form <br />Project Number, <br />(City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Properly Owner Name: (yIGI f G H ri 5�1 a KSfn S 1 mP So+t <br />Installation Address: 1816_h L og4 5 41 ___ __ <br />City: 6-fJyp-te _state: k)a Z.: q 20( <br />Mailing Address (if different): <br />City: <br />Email: <br />State: <br />Phone: A;6) ?A,3"t� <br />rr <br />Total Cost to Install Device (from contractor invoice): $ oCjal <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 rebate to the vendor does not exempt me Iron, 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 Cwner Date <br />