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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Number (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: � <br /> Property Otivner Name: C'•h V��< f�l �L nd�� <br /> InstallationAddress: � 3� � 1���?esFY�eF <br /> Ciry: � U t'.Y.�.�'E State: � �• Zip: �8 �U� <br /> Mailing Address (if di/ferent): <br /> Cily: State� Zip: <br /> Email: _Phone: (y1 s j ,Q}q, J3}p� <br /> Total Cosl to Install Device (lrom confractor invoiceJ: 5 <br /> 1, the,propeAy owner, requesi ro have the City of Everett 8ackwater Prevention Device rebate check � <br /> (or the installation of the device at the above referenced property address be made payabie to, and <br /> sent to,ihe vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the foilowing: <br /> 1. I will nol receive a rebate check directly(rom the City of Everett. <br /> 2. Assigning payment o(lhe rebale lo the vendor does not exempt me from Back�vater <br /> Prevenlion Device Rebatr. Program requirements. • <br /> I aulhorize Ihe release o(my rebate lo the vendor listed on the back of this form pending <br /> approval of the completed Backwater PrevenQon Device rebate packet by the Cily of Everett <br /> ����0,,,��i�' — 5=13� 2olS <br /> Signature of Property Owner Date <br />