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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: 'ti /�+ �/f4M � � �y�� <br />Installation Address� Zl f J %�A/N//.i� �?/�- . <br />City: �1�1:.�,� � State: L�/` ' Zip: � g LO <br />Mail�ng Address (if dilferent): <br />City: <br />Email: <br />State: <br />Total Cost to Instail Device (Irom contractorrnvoiceJ: $ <br />Zip: <br />Phone: ( <br />�- �'i <br />� h C� <br />I, the property owner, request to have lhe City of Everett Backwater Prevention Device rebate check <br />for the inslallation of the device at ihe above referenced property address be made payabie to, and <br />sent to, the vendor specified on the back of this form. By requesting ihe rebate check be made <br />payable to ihe vendor, I agree to the tollowing; <br />1. I will nol receive a rebate check directly from the City of Everett. <br />2. Assigning payment of ihe rebale to the vendor does not exempl me from Backwater <br />Prevention Device Rebate Program req�irements. <br />I authnrize lhe release of my rebate lo the vendor listed on the hack of this form pending <br />�pproval of ihe completed Backwaler Prevention Device rebate packet by the City of Everett <br />> �% � <br />� t' li-/� \ � >I <br />Signature of Properly O�vner � <br />D� le <br />g' I� <br />