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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: _ __ (Ciry to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: LC—on/A�R'T> /-�.�K�1�/� <br /> InstallationAddress: a3o� �iNE S'-r' <br /> City: �✓E2G�� State:�Zip: 98�� <br /> Maiiing Address(il diNerent): _ <br /> City: -�'� Slale: Zip: <br /> Email� Phone: (�1Sf1s���8�3� <br /> Total Cost to Install Device (Irom contraclorinvoice): 5 ��. ��' <br /> I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at lhe above refarenced property address be maL� payable to, and <br /> sent to, the vendor specified on the back of this form. By requesting lhe rebate check be made <br /> payable to lhe vendor, I agree to the following: <br /> 1. I will nol receive a rebate check direclly from the City ot Everetl. <br /> 2. Assigning payment o(the rebale lo the vendor does not exempt me irom Backwater <br /> Prevention Device Rebale Program requirements. <br /> I authorize Ihe release of my rebate to the vendor lisled on Ihe back of this form pending <br /> approval of the compieted Backwater Prevention Device rebate packet by the Ciry of Everett <br /> bl. �,�c�,-,.� 3�3��i s <br /> Signature of Property O�vner Date <br />