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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (City(o Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: f��r�i Nl Gt TA� <br /> InstallationAddress: � � Ielq���( �T1� <br /> City: �UQVQf1 State: W� Zip: a�zo � <br /> tutailing Address(if di(ferent):_ <br /> City: Stale: Zip: <br /> [mail: ��V�A�p(f (U j'►'�/� •CO✓Y1 Phone: ( ) �6 '���`�6��� <br /> Total Cost to Install Device (from contractorinvoice): $�� 1� <br /> I, fhe property owner, request b have the City of Everett BacMvater Prevention Device rebate check <br /> for lhe inslallalion of the device at the above referenced properiy address be made payable to, and <br /> sen� to, lhe vendor specified on Ihe back of this form. By requesting the rebale check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will not receive a rebate check direcUy from the City oF[verett. <br /> 2. Assigning payment of the rebate to Ihe vendor does not exempt me frmn Backwatcr <br /> Prevention Device Rebate Proc�ram requirements. <br /> I aulhorize thc release of my rebate to the vendor lisied on the back of this(orm pending <br /> approval of the completed Backwater Prevention Device rebate packet by the Ciry of Everett <br /> ,-' , _ _ . Izl1� � <br /> Signalure of roperty Owner Date <br /> � <br /> i; <br /> E <br /> I <br />