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Backwater Preventi�on Device Rebate Program <br />Vendor Pay�ment Op#ion Form <br />Project Number. __ __ (Ciry to Prov7de) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: �i^n �1 il n nr� � I) P. � I Q l ��pC,__ <br />Inslallalion Address: 3f.,� O� �C�.S �YP ._ <br />Cily: � �/ P. JC� State: ��_ Zip: ��'�n I <br />Mailing Address (il different): <br />Cily: Slate: <br />Email:�(�7, vn�v� _(�Frnni��et.c'.��rvi Phone:(Q26j�5�-�3'a2n <br />•ov <br />Total Cost to Install Device (irom contracfor invoice): $ ��� <br />I, the properly owner, request to have the Cily of Everett Backwater Prevention Device rebate check <br />for the instal{ation of lhe device at Ihe abcve referenced property address be made payahle to, and <br />sent to, the vendor specified on the back of this form. By roquesling the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. I will not receive a rebate check directty from lhe City of Everetl. <br />2. Assigning payment of the rebate to lhc vendor does not exempl nie (rorn Backwaler <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to Ihe vendor listed on the back of lhis form pending <br />approval of the completed Backwater Prevenlicn Devir.e rebate packel by lhe City of Everett <br />�.QC� C'� ��-' � � ,� <br />Signature of Property Owner Date <br />