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� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />ProJect Number: _ _Y (Ciry fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: -S A RA � ��-�/eM !G <br />InstallalionAddress: z�/a l�f�l�/lE TI VE/l%(�t� <br />c�iy: �VE�ETT state: l�/`f6 z�P:�Zo/ <br />c��y: �E�bTT[� State: �_ 2ip: �T� � <br />Em�;,:smccormi�l��/I•L'Or►1 Phone:(�6) Z�Q-• �l5ro� <br />Total Cosl to Install Devite (from contractorinvoicn): 5 <br />I, Uie property ovrner, request to have ihe Cily of Everell Backwater Prevenlion Device rebate check <br />(or the Installallon of the device al the above re(erenced property address be made payable lo, and <br />sent lo, the vendor specilied on the back of Ihis form. By requestinq the rebate checR be made <br />payable to Ihe vendor, I agree lo the followfng: <br />1. I �vill not receive a rebate check direcliy from the Cily o( Evere�t. <br />' 2. Assigning payment of the rebate to tho vendor does not exempt me from Backwaler <br />PrevenBon Device Rebate Program requirements. <br />I authorite Ihe relcase ot my rebate to the vendor lisled on Ihe back of Uils fortn pending <br />apprrnal of the completed Dackwater Pn:venlion Device rebate packet by the Ciry of Everelt <br />Signature at Property Owner <br />� <br />� ' Z5 � 245 (� <br />Date <br />