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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: (Ciry to Provide) <br />Please complete both sides af the form <br />Property Owner Section: <br />PropeRy Owner Name: �a�+-�� l� �.�s�'� ��✓��"Iv <br />Installation Address: l4 Z�F !� �^t'�`'�*� � �� �- <br />City: �i 9�.J�— Stale: �W � Zip: �5 ZO � <br />Mailing Address (ifdiHe�ent): ,�,�K�b� �� ��� �'� � <br />Cfty: C�e�o�-rt- State: F�� Zip: `�� ZO � <br />Email: ►1�r^n� C— Phone: �Eas ) 2.58 - �4 �3 <br />Total Cost to instail Device (Irom contrecfor invoice): $ 2- ���% vj� — <br />I, the property owner, request to ha�e the City of Everett Backwaler 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 lhe back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. I will not receive a rebate check directly from the City o( Everelt. <br />2. Assigning payment of the rebate to lhe vendor d.es not exempt me irom Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of �.iy rebate to the vendor listed on the back cf this form pendi�g <br />au�rovai oi the completed Backwater Prevention Device rebate packet by tlie City of Everett <br />I�l�c-�`� <br />�— � <br />�Date _ _, <br />