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u <br />�Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number _ (Giry lo ProWde) <br />Piease complete both sides of the form <br />Property Owner Sectlon: <br />- `�-- • ------ -- <br />Property Owner Name ��� t�,.i )�' i : �i.� �_ . _ _ <br />Inslallation Atldrcss �; ���f �� .; n�,� r r{U L _ <br />Cit : � IQ State �(: { _ Zfp _� �-1• � ( <br />v �._'�--- -� �__..-- -�---,- -- --- <br />Maiiing Address (if ditte�enO. __ _,. _ <br />Ciry' __ SIBIP _ <br />_. 7�u <br />EmaiP--- ----------- Phone.{� •1T :l.�i_��._�''1__.- � <br />/� C w� I <br />Total Cost to InstaU Devlce (lrom conbacfo� mvace) 5 J�."L/�� -�7 �Y; _ __ I <br />' __ ' _. _". ____. _' _"' -_' / _____' �.-_ _' ._ .J <br />I, the property oN�ner, request ro have the Clty ^f Everetl Bdckwater Prevenhon Oewce rebate cneck <br />for Ihe mstallatiori of the tlewce at the 2bove �efe�znced property adaress be made payab!e to, and <br />sent to, tha vendor specfietl on the back ot this form By requesting lhe rebate check be made <br />payable to ihe vendor, 1 agree b the foUowmg. <br />1 I will not receroe a rebate �eck d�reU�y Tom the G�ry ot Everett <br />2. Assigning payment of the rebale to lhe ventlor tloes not r,xempt me from Back�vater <br />PrevenUon Device Rebate Program reqwrements. <br />I authorize ihe rNease of my rebate to lhe vendor listed on ihe back nf 1rns form panding <br />approval of ihe completed Bockwater Preventlon Device �ebate packet by the Crty of Everett <br />.� <br />., <br />-- �).�,_ .�� ��", --- -'-���1. IS — <br />Signature of Property Owner Dato <br />-- - -- - --- -- — - - — — — -- —� <br />0 <br />� <br />e <br />