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WVfendi®r Pay meM options Form <br />Project Number. (city to vide) <br />Mum a;aaatroPloba both swez f ft f oyrar <br />Propar�yOwwre osq: <br />Property Ovemer Name: <br />C�ARy lac <br />Installation Address:_ 36o 2 Qt S "C-- -_ <br />city: e— <br />State-._ V-rAc 75p:-Y:O- <br />Mailing Address (it different): _(L'Z- P 10':7��"�- <br />City. State: hn/� S' 21p: <br />Frthail: �p.�Jo1✓S_ c�(� Ptmre:(3&4�:q 2C <br />Total Cost to Install Device (6om m7 adorinvoice): $ <br />I, the property owner, request to have the City of Everett Badwatsr Prevention Device rebate raleck <br />for the Installation of the device at the above referenced Property address be made Payable e and <br />sent to, the vendor specified an the beck of this form. By requesting the tbate check be madde <br />peyeble to the vendo. , I agree to the following: <br />1. t will not receive a rebate check directly from the City of Everett. <br />2. Assigning payhnent of the rebate tc the vendor does not exempt me from Backvrmter <br />Prevention Devioa Rebate Program requirements. <br />I authorize the release of my rebate to ffte vendor listed on the back of this farm pending <br />approval of the completed Bac!a+rater Pre mntion Device rebate packet by the City of Everett <br />Date <br />Slgnat, Ry Owrche <br />