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BackwatEr Prevention Device <br />Rebate Program <br />For internal Use: Pro�ect Numbec <br />Vendor Payment Option Form <br />Please complete both sides of the form <br />Property Owner Section (please arint): <br />� — - ----- -- -- - <br />I 'J <br />� <br />—��i�>�c_�s��` — <br />Property Owner Namc � <br />�2=� �,�-:-, (av��. ____—E�ese,-�1- ( ��p, c• ��1 _ <br />Property Address City State Zi <br />P <br />Allernate tvlailing Address City State Zip <br />_`'Ll'� 3'�'��.l�o'� __ \=,�2Z.ltiQn nm �; i <br />Phone =-�-�—.C.f_� ' , nP �' <br />[mail <br />I, the Property Owner, reyuest to have the City of Everett Back�vater Preventio� Device <br />rebate check fvr the installation referenced at ihe Property Hddress be made payable <br />to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br />:o the Vendor, I agree to the tollowing: <br />i I will not receive a Back�vater Prevention Device rebate check directly from Ihe <br />City of [verett. <br />?_. Assigning payment of the E�ackwater Prevention Uevice rebate to the Vendor <br />does nol exempt me from f3ackwater Preventiun nevice Rebale Program <br />requirements <br />I authorize the relcase of my rebalc to the Vendor listed on page two of this form <br />pending approval of the compleled Backwater Preverition Device rebate package by <br />Uie City of Everett <br />Signalure olProperty Owner <br />„..� �� <br />Date <br />Revised 9/3/2pt4 Page � of 2 <br />