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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: (City to Provide) <br />Please complete both sides of the form <br />Prnperty Owner Section: <br />Property Owner Name: <br />Installalion Address: <br />/' � . <br />/ � i '.: • I <br />Mailing Address (ifdrlferent): <br />City: State: ��P <br />Email: ✓� � G�r•L Phone: �G) � <br />. �� <br />Total Cost lo Install Device �lrom con ractor invoice): $ ��%� � <br />I, the propeAy o�vner, request to have lhe City of Everett Backwater Prevention Device rebale check <br />for the installation of the device al the above re(erenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting lhe rebate check be made <br />payable to the vendor, I agree to the follov+ing: <br />1. I will not receive a rebate check directiy from the City oi Everelt. <br />2. Assigninc� p2yment of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requiremenls. <br />I aulhorize the release of my rebale to lhe vendor listed on the back of ihis form pending <br />approval of the compteted Backwater Prevention Device rebate packet by the City of Everetl <br />Owner <br />�S <br />Date <br />