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e <br />Backwater Prevention Device Rebate Program <br />� � Vendor Payment Option Form <br />Project Number: (Ciry fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Umer Name: —i1 i�7 <br />Inslallation Address: _ � <br />cib�_,�'.�d +C�T_ <br />Malling Address (ildrNerent): _ <br />�'�_ <br />�� • ��� <br />Ciry; Stete• Zip' <br />Email: Phone: ( ) <br />Total Cost lo Install Device (1rom conhacforinvoice): S(,�5��. �� <br />1, the property owr , rtiquest to have the Clty of EvereB Backwater PrevenUon Device rebate check <br />for Ihe Installalion �f the device at the abovn referenced property ad6re9s be made peyable to, and <br />sent to, the vendor specifled on the back of this torm. By requesting Ihe rabate check be made <br />payable to the vendpr, 1 agree lo lhe following: <br />1. I will not recewe a rebate check dlrecUy ham Iho Gty of Everett. . <br />z. Asslgning payment ot the rebate 10 the ventlor does not exempt me trpm eackwater ' <br />Prevention Device Rebale Pm�ram requiremente. <br />I authorizo the release oi my rebate to Me ventior Ilsted on the back of this toml pe0dfng <br />approvai ol the completed Backwater Provention Device rebale packot by the City of EvereR <br />iature o( Property <br />. ��-.�� <br />�a <br />e <br />