Laserfiche WebLink
Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: (City to Provide) A <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: -J 0.Yyvr'S E' 1 �r^-Yyf <br />Installation Address: 3SU 7 Qe,`f /}r— <br />City: r ti+ d S f _State. t-r,'E% Zip: (9rz U I <br />Mailing Address (if different): <br />City:, <br />Email: <br />State: Zi <br />Total -Cost to Install Device (from contractor invoice): $ <br />Phone:( <br />I, the property owner, request to have the City of Everett,Backwaler Prevention Device rebate check <br />for the installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the -back of.this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. 1 will not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the completed Backwater Prevention -Device rebate packet by the City of Everett <br />Signature of Property Owner <br />Date. <br />