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Backwater Prevention Device Rebate Frogra�m <br />Vendor Payment Option Fo.rm <br />Project Number: (Cify to Provide) <br />Please complete both sides of the form <br />Property Owner Section: . ,� <br />Property Owner Name: <br />Installation Address: __ 2�p� / ��( i Yl i eV v�ll P� V <br />City: �l/LI%Q TT ' State: � Zip: �t� r� U' / <br />Mailing Address (if dif(erent): <br />City: State: <br />Emaii: 1rOXCt �_ '1►�� iAGi ��f I�VL15. Co mPhone: �2� �/�Y ��o XS�. <br />Total Cost to Inslall Device (fiom contractor invoicef S <br />I, the properly owner, request to have the City oF Everett Backwater Prevention Device rebale check <br />for the installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on lhe back of lhis form. By requesling ihe rebate check be made <br />payable to ihe vendor, I agrec to the following: <br />1. I will not receive a rebate check directly from the City of Everetl. <br />2. Assigning payment oi ihe rebate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I aulhorize the release of my rebate to the vendor listed on the back of lhis form pending <br />approval of the completed Backwaler Prevention Device rebale packet by the City o( Evere�l <br />��. � L <br />V I <br />Sign ture of Property Owner • Date <br />`����« J`���*--�� � - aa " <br />