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Backwat�r Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. (City fo Provide) <br />z <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner �Jame: �,q � L�/V � • / �.� %—.�2 <br />Installation Address: /9 �� !ri C/�O UGi3 � L- /� 4C <br />City' L- (i� R�T 7— State: �/C/1� Zip: -�f' `7� �� / <br />Mailing Address (il d!Nerenf): <br />City: _ State: <br />Email: <br />Phone: ( <br />Total Cost to Install Device (trom contractor invoice): $ �'-f- � ���T <br />I, the property owner, requesl 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 ot this form. By requesting the rebate check be made <br />payable to lhe vendor, I agree to the following: <br />1. I will not receive a rebate check direclly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does nol exempt me (rom Backwater <br />Prevention Oevice Rebate Program requirements. <br />I authorize the release of my rebate to lhe vendor listed on ihe back ot this form pending <br />approval oi the completed Backwaler Prevention Device rebale packet by the Cily of F_verett <br />L� � ��_ � � <br />Signature of Property Owner <br />Date <br />