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Backwater Prtl��p��tion !�evice Rebate Program <br /> �endor Payment Option F�rm <br /> ProJect Number: _ (City to Pm✓ide) <br /> Piease co�nplefe bot•%i sides o�ii�e foi�rn <br /> Property Owner Section: <br /> Property Owner Name: � �° �r ` � � ��f l�J Y <br /> Installation Address: I % U� �"�� �'�`� �� ���2 � v � <br /> ��ry: E vE2 � ►i S�d�e: ��R _��P: �l g La I <br /> iviailino Addres�(if drflerent): — <br /> Clly: Stale:� Zlp:,_ <br /> Email: ��(nc�re�r 1�,�un �ho"tYhqf�. CAYn Phone: (Zo6�7q3 ' SZg7 <br /> Tutal Cost to Install Device (Irom contracforinvoice):S �'`�99.59 <br /> I, the property ovmer, requesf to have the Cily of Everelt Backwater Prevention Device reba�e check <br /> for the inslallation of the devics at Ihe above referenced property address be made payable to, and <br /> sent to, the vendor specified on ihe back of lhis form. By requesting lhe rebate check be made <br /> payzble to the vendor, I agree to the toltowing: <br /> 1. I �vill not receive a rebale check dlrecUy from lhe Cily of Everett. <br /> 2. Assigning paymenl of the rebate to the vendor does not exempt me from Backwater <br /> Prevenlion Device Rebale Program requirements. <br /> I authorize the release of my rebalu to ihe veiidor listed on the back of this fomi ponding <br /> approval oF the cornpleted Backwater Pre��enlion Devlce rebale packet by the Ciry of Everetl <br /> �jd'� Q�- (�' t�r/ � Z� � $ <br /> Signatura of Property Owner Date <br />