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1 <br /> Backwater Prevention Device <br /> Rebate Program <br /> For internal Use: Project Number: _ <br /> Vendor Payment Option Form <br /> Please complete both sides of the form _ <br /> Property Owner Section (please print): <br /> � <br /> Propert Owner Name <br /> Property Address it State ��Zi� <br /> 3��(� cX' �csn �v �e;�.2�- <br /> iternate Mailing Address City State Zip <br /> � �k �� ����� ��, �p � ��a�� <br /> Phone Email: (Yll)1�i � ���CtGQI,��e(,Yyr��, ��- <br /> � �I�S - �'u� - � IFr� <br /> 1, the Property Owner, request to have the City of Everett Backwater Prevention Device <br /> rebate check for the installation referenced at the PropeRy Address be made payable to, <br /> and sent to, the Vendor. By requesting the incentivefrebate check be made payable to the <br /> Vendor, I agree to the following: <br /> 1. I will not receive a Backwater Prevention Device rebate check directly from the <br /> City of Everett. <br /> 2. Assigning payment of the Backwater Prevention Device rebate to the Vendor <br /> does not exempt me from Backwater Prevention Device Rebate Program <br /> requirements. <br /> I authorize tlie release of my rebate to the Vendor listed on page two of lhis form pending <br /> approval of the completed Backwater Prevention Device rebate package by the City of <br /> Everett , <br /> , _ __ _ -+ � �-i <br /> ` -1.3..�:.:c,:�- - .� .��_- c,(����- - _ _ f— .��%'�. <br /> l <br /> � <br /> Signature o(Property Owner Date <br /> Page 1 of 2 <br /> Revised 9I3/2014 <br />