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4�Backwater Prevention Device <br />rr Rebate Program <br />'--or internal Use: Project Number <br />Vendor Payment Option Form <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />---- <br />f?ropeify Ovarier Name' <br />p <br />(Piopertty/Address <br />City Stale <br />(Zip <br />A10r ate Mailing Address ' <br />'City State <br />f. Zip <br />YzJ �Cc;t cok, <br />;Phone <br />tEinail <br />I, the Property Owner, request to have the City of Everett Backwater Prevention Device <br />rebate check for the installation referenced at the Property Address be made payable <br />to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br />to the Vendor, I agree to the following: <br />1. 1 will not receive a Backwater Prevention Device rebate check directly from the <br />City of Everett. <br />2. Assigning payment of the Backwater Prevention Device rebate to the Vendor <br />does not exempt me from Backwater Prevention Device Rebate Program <br />requirements. <br />I authorize the release of my rebate to the Vendor listed on page two of this form <br />pending approval of the completed Backwater Prevention Device rebate package by <br />the City of Everett <br />&,-� // a 1� <br />rSignafure of Property Owners fDafe; <br />Revised 913/2014 <br />Page 1 of 2 <br />