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Ba�kwater Pr��vention Device Rsbate Program <br />Vendvr Payment Option Form <br />Project Nwnber __ ,______ (Ciryto Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />PropeKy O�vner Name: <br />Installation Add•ess: C�f l�_ I`"l�,_� t�"�. >r I �\V�_ <br />City: f��;' �"�' � State: �J �` Zip:� 9��( <br />hlailina Addre: s (il dillemnQ: <br />Ciry: _ Stale: Zip: — — <br />Email _ 'i 1 � � ��M h� ��,�1 �C� phone: ( ) __`� � J [�8�`� <br />Total Cost to Install Device (/rom confractor im•oice): $___ � <br />I, the property ovrner, raquest to have Ihe City o` Everett Backwater Prevention Device rebate check <br />for ihe mstallalion o( the device at thc above reterenced property address be made payable to, and <br />sent to, the vendor specified on the back o( this fomi. By requesting the rebate chec'< be rnade <br />payahle lo the vendor. I agrce lo the followina: <br />1. I will nol receive a rebale check direcUy (rom lhe City o( Everell. <br />2 Assigning payment o( the rebate lo lf�e vendor does nol exempt me from B2cke�alcr <br />PrevenUon Device Rebalc Program recuirements. <br />1 authorize the release of my rehate to Ihe vendor listed on the h�; k oi this form pending <br />approval u( the cornpleted Back�valer Prevenlion �evice rebate packel by Ihe Cily o( Everett <br />� `,�,_ 1. <br />n, n• �_ ��� <br />Signat re o( Property wner Date <br />� <br />