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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Numbec _ _______ __ (Ci(y fo P�avide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vner Name: � �'��`�J('w\ l\��ISC�� �v�.�01r. <br />InstallationAddress•_�•�C�� ��c�C�.LC-�C-�.�-�-�\ ��`IL' <br />Cily: �iVC-Y (i� Slate: 1;V'i� Zip: � �1�� ( <br />tvlailing Address (i(dilferenf): <br />City: Slate: Zip:_ <br />�� <br />Email: ��-C.CO\�1� 0�1 (�v�;'�n'��'�,_>2.1 ��P Jl�whone: ( ) d-� z �1�i 4l <br />Tolal Cost to Install Dewce (/rom contracfor invoice): S ����7 ��� <br />I, the property owner, request to have the City of Everelt Back�vater Prevention Device rebate check <br />for lhe mslallation ot lhe device at the above referenced property address �e made payable to, and <br />sent to, lhe vendor specified on thc back o( this (orm. By requesting �he rebale check be made <br />payable b lhe vendor, I agree to the follo�ving • <br />1. I will not receive a rebate check dueclty from Ihe City of Everetl. <br />2. Assigning paymenl of the rebale to the vendor does not exempt me from Oack�valer <br />Prevenlion Device Rebale Program requiremenls. <br />I authorize the release of my rebale to the vendor listed on Ihc back of ihis form pending <br />approval of the complcled Backwater Prevenlion Device rebate packet by the City of tverett <br />�>��al�.� ' l' ��t`�V��.��. _ 3 l� �t-�1�� <br />Signalure of Proper�y Ovmer Da�e <br />