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I <br />Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. <br />(City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name' _'_ 5. ✓vrtJ_ ( /�!�/ - Installation Address: <br />Address: <br />City: G 1, 'c r StatetAl / Zip <br />Mailing Address (d ddlerant)' <br />City: <br />State. <br />Email: _ Phone ( ) <br />Total Ccsl to Install Device (from contractor invoice) $ _ y. '. • '- <br />1. the property owner, request to have the City, of Fveretl Baokwater Prevention Device rebate check <br />for the installation of the devl,.,o at thu above reforenced property address be made payable to, and <br />bent to, the van dur specified on the back of this form By requesting the rebate check be made <br />payable to the vendor, 1 agree to the following. <br />1. 1 wilt not receive s rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does uol exeinpl me kurn Badwaler <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the completed Backwater Preventlon Device rebate packet by the Cny of Everett <br />Signature of Property Owner Date <br />i <br />