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Backwater Prevention Device Rebate Program <br /> Vendor Payment �Dption Form <br /> Projecl Number _______ (City to Pmvide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: � be� � W. ���,� — -- - <br /> InstallalionAddress: �tiry� �0��' r���F 2 ��_ <br /> a�y �E�E�`7 _ s�,�e: "' lt z�P: �I6�/ <br /> i�9ailing Address (7dilferent): <br /> City: State: Zip: <br /> EmaiC _ _Phone: ( )_ I <br /> To;al Cosl to Inslall Device (from conhactor invoice): S ��}'�� /. %U <br /> I <br /> I, Ihe property owner, requesl to have the City af Everelf E3ackwaler Prevention D^vice rebale check <br /> br lhe inslallation of the device at the above referenced property address be made payable to, and <br /> sent to, the vendor specified on ihe back of Ihis form. [3y requesting the rebate check be made <br /> payable to the vendor, I agree to the followinG: <br /> 1 I �vdl not recewe a rebale check directly from lhe City of Everetl. <br /> 2 nssignmg paymenl o(lhe rebale to the vendor does not exempt me from Back�valer <br /> Prcvenlion Device R^bate Proyram requirements. <br /> I aulhorize the release of my rebate lo ihe vendor hsted on the back of this form pending <br /> approval of the completed BacKwater Prevention Device rebale packet by the City of Everelt <br /> ��1��`u/ . l'.�(✓t�� _ Z 3- �0/y� <br /> Signalure of Property Owner Dale <br />