Laserfiche WebLink
Backwater Prevention Device <br />Rebate Program <br />For in"ernal Use: Project Number: <br />Vendor Payment Option Form <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />JU k Vi s tov\ — <br />Property, Owner Name --'— <br />Property Address -- <br />3N ✓^r <br />11 OclKey A✓e Cily 'Cw Dale i , w /+Z1pp�oZ�' <br />Alternate Mailing Address City�—I <br />Slate Zip <br />Phone .2S-as9-39?_7 Email <br />I, the Property Owner, request to have the City of Everett BackwaterPreventionDevice <br />rebate check for the installation referenced at the Property Address be made payable <br />to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br />to the Vendor, I agree to the following: <br />1. 1 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, the; release of my rebate to the Vendor listed on page two of this form <br />pending approval of the completed Backwater Prevention Uevice rebate package by <br />the City of;Everett <br />Signature of Pioperty Ownor <br />T- <br />Date <br />Revised 9912014 Page 1 of 2 <br />