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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Number. (City to PiovideJ <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: � <br />Installation Address: �i �� IYIi ��Q �-+��IC <br />City: � ��E/1 C%! State: �cJd __Zip: �Q�2D� <br />Mailing Address (if dilferenf): <br />City: Slate: Zip: <br />i ` �Email: Phone: �—$Z�-7 �/ <br />� <br />Total Cost to Install Device (Irom contractor invoice): 5���� �^ <br />I, lhe property owner, request to have the City of Everett Backwaler Prevenlion Device rebate check <br />(or the installation of lhe device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on ihe back of this form. By requesting the rebale check be made <br />payable to the vendor, I agree lo the following: <br />I will not receive a rebale check direcliy from the Cily of Everelt. <br />2. Assigning payment of the rebate to the vendor does not exempt me trom Backwater <br />Pre�ention Device Rebate Program requiremenls. <br />I aulhorize thc release of my rebate to the ver.Jor listed on the back of this form pending <br />approval of ihe completed Backwater Prevention Device rebate packet by lhe City of Everelt <br />�•'( <br />ignature of Property O�vner <br />i � <br />Date <br />