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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: <br />(City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: l ���0 } I <br />Installation Address: l4/O c <br />City: aerk State: <br />Mailing Address (if different): <br />City: <br />State: <br />Zip: 9S2,6/ <br />Zip: <br />Email: elf I D-e— (p, lis t"' - co4-1 Phone: (t2,) Z�--24-40 f <br />Total Cost to Install Device (front contractor invoice): $ � 1Q0 mil% <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 from Backwater <br />Prevention Device Rebate Program requiremonls. <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 Properly Owner Date <br />