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Backwater Prevention Device Rebate Program <br />00 ff Vendor Payment Option Form <br />Project Number (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />installation Address: -�?� la`s cS ITv e/ <br />City: C� _ State: Wa Zip: laze j <br />Mailing Address (if different): <br />City: _ State: _ <br />Email. Phone: (Scj )) ?ql - JfJ SD <br />Total Cost to Install Device (from contractor invoice): 5 a4-6l.. Q_2 <br />I, the property owner, request to have the City of Everett Backwater 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, 1 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 requiremenfs. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval'oitthe completed Backwater Prevention Device rebate packet by the City of Everett <br />Signature of <br />-� 1-17 <br />f 5' <br />Date <br />