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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Numoer: (City to Provide) <br />Piease complete both sides of the form <br />Prope:ty Owner Section: <br />�. <br />Property Owner Name: �UC� � � <br />InstallationAddress ��Onl .0 C�(' flU� <br />City: �V �'1�P.� State: Ia ;� Zip: -1 �'� � <br />Mailing Address (if diflerent): 5�n'lR_ <br />City: <br />State: <br />Zip: <br />EmaiL• �� OC� , b i Gl .(UZiJ C� �'15�1. CGlY� Phone: (4i� z4�8 -i�iv �� <br />Total Cost to Install Device (irom contractorinvoice): $ <br />I, the property owner, request to have the City of Everett Backwater Preventlon Device rebate check <br />for the installation of the device at the above ref�renced properly address be made payable to, and <br />sent to, the vendor specified on the badc of this fortn. By requesting the rebate check be made <br />payable to the vendor, l agree to the foilowing: <br />1. I will not receive a rebate check directly from the City of Everelt. <br />2. Assigning payment of the rebate to the vendor does not exempt me from 8ackwater <br />Prevention Device Rebate Program requirements. <br />1 authonze the release of my rebate lo the vendor lisled on the back of this form pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />,�� . ��' <br />, <br />ignature of P"operty Owner <br />// -�e-ly <br />Date <br />