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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: <br />(Cify ro Previde) <br />Please complete both sides of the form <br />Property Owner Section: <br />Propert/ O�vner Name: l A E T 1J `- �.�+ l�0. 2 i � <br />installation Address: ,j°/�z O�dk�`�_,•'1 �L __ � <br />City C- U� �a�r`� State: W� . Zip: �`6�� I _ <br />fvlaiting Address (if diNerent) <br />City _ <br />Email: <br />State: <br />Total Cost to Insfall Device (from contractor invoice) 5 <br />Phone: (�-R�i _f` 93 - j Z i o '� <br />�L, a' �' <br />---- ---- --� <br />I, the properly o�vner, requesl lo have Ihe City of Everett Back�.valer Prevention Dewce rebale check <br />for the installabon of the device at the above refe� �iced property address 6e made paya6le to, and <br />sent to, lhe vendor specilied on the back of ihis t m. By requesling lhe rebate check be made <br />payable lo the vendor, I agree to Uie (ollovnng: <br />1. I �vill not rer.eive a rebale check directly iram the Cily o( Everefl. <br />7.. /lssignmg payment of ihe rehale to Ihe vendor does nnt e;cempt me from E3ackwaler <br />Prevenlion Dewce,Rebate Program requirements. <br />I aidhonte the release of my rebale to the vendor listed on lhe back of this form pending <br />approval of the r.ompleted Dacke�ater Prevenl�on Oevice reba?e packet by the City ot Everett <br />' � 1�)J �,c�, <br />���--- <br />� Signature of Properiy O�vner <br />.3-�� /5 <br />Date <br />