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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: _ (City to Provide) <br />Please complete both sides of the form <br />Rroperty Owner Section: <br />Property Owner <br />Installation Addr� <br />Cit�r.�i� State:�_Zip: _ LCJ�Q 1 <br />Mailing Address (ildiHerentJ: <br />City: Slate: ZiP: <br />Emai� . �G (�t D � P on :� �� �� � <br />Total Cost Install Device ((rom contractor voice): $ <br />I, the propeRy owner, request to have the City of Everett Backwaler PrevenGon Device rebate check <br />for the installation of the device at the above referenced property address be made payable lo, and <br />sent to, the vendor specified on the back of this form. By requesting the rebale check be made <br />payable to the vendor, I agree to the following: <br />1. I will not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebale to the vendor listed on the back of this fortn pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />� Y v <br />S' n ture o roperty Owner <br />� /L <br />l <br />'• Da'te <br />