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Backwater Prev�ntion Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Number. (Cdy to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />PropeAy Owner Nama: <br />Installatlon Address: <br />Ci1y: i- �� � � <br />Mailin Address(ildiHerent): 1 <br />Gty. � <br />� �-�� <br />emaf�: �j,J��. — sw,x�t,_Q <br />Total Cost lo Install Device (from � <br />� ., � l �� w ��' 1�— <br />� � y �`i k� � <br />State: r� � Zp� <br />� G 1 fJ'-J 7j +�. t <br />I, llie property owner, request to have the Ciiy of Everetl Backw2ter PreveNinn �evice �ebale check <br />for Ihe inslallaUon of the device at the above relerenced propoAy address be made payable to, and <br />sent lo, Ihe vendor specltied on the bac.k of this (orm. By requestlnp the rebate check be made <br />payabie Io the vendor, I agrer lo the follnwinpt <br />1. I WIII 110t ffCP,IVO 8 fADAIC CIICfa( dI1CClly (fORI fh0 Clly O( FVCtCII. <br />2. Asslgnlny paymcnl ol the reb�ile tu Ihe vendor does nul exempl me (rom Dackwalcr <br />Prevention Device Rebat� Program requirements. <br />I aulhorizo thu rcicase ol my roUale to the vendor IisleJ un Uie back of this lorm pending <br />approvai of lhe comp�etr.d Rackwater Frever;ion Device mbale �ar.ket hy tha City of Everett <br />—( _ J__�.i—� '�. <br />Signaturn ot Property Owricr <br />r <br />