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.y <br /> Backwater Prevention Device Rebate Program� <br /> Vendor Payment Option Form � <br /> Project Numher. (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: � «+� �'"'�y"rr <br /> Installation�ddress: L�� I OGk�� � • <br /> Ciry: C�/e�e -�" State: �'✓I`� zip: 9Bzo I <br /> Maiting Address(i(diflerentJ: <br /> City: Slate: Zip: <br /> Email: Phone: ( ) <br /> Total Cost to Install Device (Irom confractorinvoice): 5 �.Saa _ <br /> I, lhe property owner, request to have the City of Everetl Backwater Prevention Device re6ate check <br /> for�he installation of Ihe device al ihe above referenced property address be made payable lo, and <br /> sent to, the vendor specdied on the back oi this torm. By requesting the rebate check be made <br /> payabie lo Ihe vendor, I agree to the following: <br /> 1. 1 will not receive a rebate check direclly irom the City of Everetl. <br /> 7.. Assigning payment of Ihe rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebalc Program requirements. <br /> I aulhorize lhe release of my rebate lo lhe vendor listed on Ihe back o(this form pending <br /> approval ot the compleled Backwater Prevention Device rebate packet by Ihe City of Everett <br /> �,�� � �-v�""- � tL 3 � 2o y <br /> Signature of Property Owner Date <br />