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1 <br /> S <br /> � <br /> Backwater Prevention Device ; <br /> Rebate Program � <br /> For inlernai Use: Project Number: � <br /> 4 <br /> Vendor Payment O�tion Form �� <br /> Please complete both sides of the form � � <br /> � � <br /> Property Owner Ses:tion (please print): � <br /> ; <br /> V1�t�Ceor_n� F _ � i-1-N��t- w1 l�vlo S�'s ' <br /> Propt•',y Owner Name � <br /> �` -rL-1`7 nOCI�I:'FC:.��t�'�2 (ir�v C(IL�It'L?T �!1--� �'7�.Z0 / <br /> Property Address City Siate Zip � <br /> �23`1_ 11'S�" id�r Sc S'NU, _ w� J�6'2Yu <br /> Altemate Mailing Address City State Zip ; <br /> .`z0� (o — 8 tc� •- $33 l <br /> Phone Email � <br /> I, the Property Owner, request to have the City of Cverett Backwater Prevention Device � <br /> rebate check for the installation referenr,ed at the Property Address be rnade payable <br /> to, and sent io, tho Vendor. By requesting the incantivelrebate check be made payable i <br /> to the Vendor, I agree to the following: <br /> i <br /> 1. I will not re:eive a Backwater Prevention Device rebate check directly from the <br /> City of Everett. <br /> 2. Assigning payment of the Backwater Prevention Device rebate to the Vendor ! <br /> does nct exempt me from Backwater Prevention Device Rebate Program � <br /> requirements. ; <br /> 1 authorize the release of my rebate to lhe Vendor listed on page two of this form ; <br /> pending approval o(the completed Backwater Prevention Device rebate �ackage by <br /> the Ci of Everett i <br /> i <br /> 3 � � �— <br /> Signature Properiy Ow�ner Date ± <br /> j <br /> i <br /> 1 <br /> Page 1 0(2 <br /> Revised 9I3I2D14 <br /> i <br /> � <br /> i <br /> � <br /> .�. <br />