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M- <br />0;Backwater Prevention Device Rebate Program <br />4rr Vendor Payment Option Form <br />Project Number,_rr cf (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property owner Name. / dt-y 1" 'e — <br />Installaton Address: t 9 Q@-AL--catcxlL__L1. -- <br />City: {.. — — State: 1A j A cObi— _ LP--qit1X12/ <br />Mailing Address (if different): <br />City - <br />Email: <br />State: _ <br />Phone. ( ) <br />Total Cost to Install Device (from confractor involve): $ <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 nbovo referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the mb.le check be made <br />payable to the vendor. I agree to the following: <br />I will not receive a rebate check directly from the City of Evereh. <br />2. Assigning payment of the rehale •c Ihn 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 font pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />S aare of Prop y Owner Date <br />