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� <br />Backwater Prevention Device <br />Reba�e Program <br />For internal Usc: Project Numbe•: <br />Vendor Pay�mert Option Formi <br />i'lease complete both sides of the form <br />Property Owner Section (please print): <br />-- C ! i-if�•� � �� ���r_ <br />'Property Owner iVame <br />� ^ � J 7,1`i a�:�� :ea �{-�e c�—�r�ti�� li.')� �b,'C/ _ � 2.c <br />Property Address '�City � ' �itate ' Zip .- <br />Alte�nate hlailing Address' City �� State � Zip � <br />�'2�- 2�4;- If:�. , <br />Phone � <br />Finail <br />I, tiie Property Owner, request to have the City of Everett Backwater Prevention Device <br />rebate check for the instaliation referenced at ihe Property Address be made payable <br />to, and sent iq the Vendor. By requesting the incentivelrebate check be made payable <br />lo the Vendor, I agree to the follc�wing: <br />1. I wiil not receive a{3ackwater Prevention Device reoate check directly irom the <br />City of EveretL ' <br />Z. Assiyning payment of Ihe Backwater Prevention Device rebate to the Vendor <br />does not exempt me from Backwater Prevention Device Rebate Program <br />requirements. <br />I authonze the release of my rebate to lhe Vendor lisfed on page h��o of this form <br />pending approval of lhe compleled Back���ater Prevention Device rebate package by <br />the City of Everett ' <br />.� � ' <br />� ,� i <br />—�..f � �,y/� <br />, . %- �� <br />�Si nature'olPr e�i O�aner <br />9 N Y � D3te_, v <br />Page 1 of 2 <br />Revised 913/2014 <br />