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Backwater Preventie�n Device Rebate F'rogram <br /> Vendor Payment Option Form <br /> Project Numbec (City to Piovidr.) <br /> Please compiete both sides of the form <br /> Property Owner Section: <br /> I P or perty Owner Name� �c...,f K..d,c�L ___ _ <br /> � <br /> Installation Address: .,C�i �1 }7,�.� fi _ <br /> Gty: _��r-�u1, State I J� Zip:���t• I <br /> Mailing Address (if dilfeienU:�1 T�� U,C 4t Q..� -;t � <br /> n <br /> City: ��,�\ State:Ir�A Zip: �<<' 7 <br /> Email: Phone: (471 )_���'�f�L <br /> Total Cost to Inslatl Device ((rom confractorinvoice): $ 2Ffo�'� <br /> I, lhe property o�vner, request to have �he City of Everelt Backwater Prevention Device rebale check <br /> for the instaliation of lhe device al the ahove referenced property address be made payable to, and <br /> sent to, the vendor speci(ied on lhe back o(Ihis form. By requesting lhe rebate check be made <br /> payable to the vendor, I agree to the tollowing: <br /> 1. I will not receive a rebate check direcUy (rom the City of Everett. <br /> 2. Assigning paymenl of lhc rebate to the vendor does nol exempt me lrom Backwaler <br /> Prevention Device Rebale Program reqwrements. <br /> I aulhorize the release of my rebate lo the vondor lisled on lhe back of this (orm pending <br /> approval of the cornpleted Backwater Prevention Device reba�e packel by the City of Everetl <br /> ���� _ �-� - �s <br /> Signature oi Properiy Owner Date <br />