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, <br /> ; <br /> Backwater Prpvention Device � <br /> RebatE. Program ; <br /> For intemal Use: Project Number: <br /> Vendor Payment Option Form `. <br /> Please complete both sides of the form <br /> Property Owner Section (please print�: ' <br /> �le.�tw l�c.�����v� <br /> Property dw�er ame <br /> 1 I 1'? 1`�+u�l� Auc , �_v�o-tC� W� �Qi 7S�� <br /> � <br /> Property Address City State 7_ip <br /> �Q �nx S2$(�S T1�IleUv� �� �'�l5 <br /> Altemate Mailing Address City State Zip � <br /> ��ZS—�� ( '���5 <br /> Phone Email <br /> I, the Property Owner, request to have the City of Everett 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 check be made payable <br /> to the Vendor, I agree to the follo�ving: <br /> 1. I will not receive a Backwater Prevention Device rebate check directiy from tne <br /> City of Everett. <br /> 2. Assigning payment of the Backwater Prevention Device rebate to the Vendor <br /> does not exempt me from Backwater Prevention Device Rebale 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 Backwater Prevention Device rebate package by <br /> the Ciry of Everett <br /> ���� ' �9�i5 <br /> Signature o/Properiy Owner Date <br /> i <br /> Page 1 oi 2 <br /> Rev�sed 9f372014 ' <br />