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Backwater Prevention Device <br />Rebate Program <br />For internal Use: Projecl Number: <br />Vendor P:a�ment Option Form <br />, Please complete both sides of the form <br />f'roperty Owner Sertio� (please print): <br />S C, Fm �,�,e �j;� ISo <br />Property.Owner Namc <br />3s� � -aa ��� <br />Properly Address <br />Alternate Mailing Address <br />y- Z�-�. � 0--] d l� U <br />'Phone � I <br />C4ty <br />Email � <br />L i�Ereff ��/ <br />Slate ; <br />, : State . <br />�zo <br />Zi� <br />Zip <br />!, the Property Owner, request to have the City o( �verett Backwater Prevention Device <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 r,heck be made payable <br />to tl�e Vendor, I agree to the (ollowing: <br />1. I wilf�not receive a Backv,�ater Prevention Device rebate check directly from the <br />City of Everett. <br />2. Assigning payment of the Backwater Prevention Device rebate to lhe Vendor <br />does not exempt me from Backwa;er 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 E3ackwater Prevention Device rebate package by <br />the City of!Everett <br />n /%l� <br />. �A _�'J '✓�,�. _� � / 7 -/,� — <br />Signature oi Properiy Owner Date� <br />Revised 9/3l2014 <br />Page 1 of 2 <br />I <br />