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i <br /> Backwater Prevention Device Rebate Program � <br /> Vendor Payment Option Form ! <br /> � <br /> ProJect Number. (Cify to Provide) i <br /> i <br /> 1 <br /> i <br /> Please comptete both sides of the form ! <br /> I <br /> Property Owner Section: : <br /> i <br /> Propert� Ovmer Name: �j,/���{,j��}�f(�� ! <br /> Installation Address: �f��a�- 1�1 n e�(1 <br /> City: ��f'.�-l1 State: ���Zip -!G �� � <br /> ' Mailing Address (if dil�erert): ��G�E ; <br /> I City. Slate' Zip: <br /> I EmaiC �f_�1�� ��%ek�d�am Pno�=: N2S �39-�.�Ca,c � <br /> �� e� o p <br /> Total Cost to Install pevice (tiom con,ractor mvoice): S � JQ(�_ <br /> i <br /> _, <br /> I, the property owner, ;equest to have the City of Everett 8accl�a;er Prevention Device rebate check <br /> `or the installation of the device at the above referenced proper'.y address b� made payable to, and <br /> sent to, the vendor specified on ,he back o'this ferm By requesUnq the re5ate check be made <br /> pay�ble to the vendor, I agree to the'ollosv:ng. <br /> 1 I will not receive a rebate check d�rectly from the City of Everett. <br /> 2. Ass�gning payment of the rebate to the vendor does not exempt me from 8ackwater <br /> Prevention Devir.e Rebate Program requirements. <br /> I authenze the release ot my rehate to the vendor listed on the back ot this torm pend�ng : <br /> approval of the completed Backv:ater Prevention Device rebate packol hy lhe Cify of EvereU ; <br /> I <br /> C ���___ _ � �3�� <br /> Signat e f Property Q�ner �ate <br /> t <br /> � <br />