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i <br /> � <br /> Backwater Prevention Device <br /> Rebate Progr�m <br /> For internal Use: Projcct Number. <br /> Vendor Payment Option Form <br /> Please complete both sides of the form <br /> Property Owner Section (please print): <br /> G�a,� � ��a,� l��,��,,� - �ha�� <br /> PropertyOwneyName <br /> al c9y aS oc.1'� -�'c11er �e �vc�:rt �,'�I•'} �F�. OI <br /> Property Address City State 2ip <br /> Altemate A4ailing Address City State Zip i <br /> �-fo�S c�SB �loa` Suz�cs�Z,c,r{S;� nc,�zPro •,�-t � <br /> Phone Email � � <br /> � � <br /> I, the Property Owner, request to have the City of Everett Backv��ater Prevention Device � <br /> rebate check for the installation referenced at the Property Address be made payable i <br /> to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable � <br /> to the Vendor, I agree to lhe following: � <br /> 1. I will not receive a Backwater Prevention Device rebate check directly irom the <br /> City of Everett. <br /> 2. Assignin� payment ot the Backwater Prevention Device rebate lo the Vendor <br /> does not exempi me from Backwater Prevention Device Rebate ProSram <br /> requirements. , <br /> I <br /> I authorize the release of my rebate to the Vendor listed on page two of this form � <br /> pending approval of the completed Backwater Prevention Device rebate package by � <br /> the City of Everett <br /> � <br /> / <br /> �� " --, - >�/� /l� <br /> Signature of Properiy Owner Date <br /> Page 1 of 2 <br /> Revised 9/312014 <br />