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„ i <br /> Backw�ter Prevention Device <br /> ��� ReV�ate Pr�ogram <br /> For internal Use: Prpject Number: _____A <br /> Ver�clor Pa�ment Option Form <br /> Please complete both sidesiof the form <br /> Property Owner Section (please print): I <br /> � �/L/- /� �U D iF/L�L r I J <br /> � •Property Ovmer Nam�e - l� � 11 <br /> �_��_—� c�n�? � � ,P �” l�-s�G �re.-�c7 -� <br /> , Propeiiy Address (--C' i State 'Zip <br /> � �� � � � v � � <br /> Aitemate Niailing Address ;�i�y i Stale � Zip <br /> �2s �-3o � - 13 �i 1 ' — <br /> Phone ' Email i <br /> � <br /> I, the Property O��ener, request to have the City of Eve'rett Back�vater Prevention Device <br /> rebate check for the installation referenced at the Property Address be made payable <br /> to, and s��nt to, the Vendor. By requesting the incentiv,e/rebate check be made payable <br /> to the Vendor, I agree to lhe follo�ving: ; <br /> I <br /> 1. I will not receive a Backwater Prevention Device rebale check directly irom the <br /> City of Everelt. i <br /> 2. Aesigning payment of the Backwater Preveniion Device rebate to the Vendor <br /> does not exempt me from Back�valer Prevention Uevice Rebate Program <br /> requirements. I <br /> ; <br /> I authorize the release of my rebate to the Vendor lisled on page two oi this form <br /> pending approval of the completed Qackwater Preve�lion Device rebate package by <br /> the Ciry of Everetl � ; <br /> i <br /> � <br /> ������! . �/3�/� s <br /> -- ; <br /> � Signa.lure o!Property Owner - i Dafe <br /> __ I <br /> I <br /> f <br /> I <br /> Parie 1 of 2 <br /> Revised 9/3/2014 i <br />