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OOLBackwater Prevention Device Rebate Program <br />Vender Payment Option Form <br />Project Number _ (City to Provide) <br />Please complete both si&, -)f the form <br />Property Owner Section: <br />Property Owner Name: <br />YOC kL <br />Installation Address: ��� � ocke&>'§t— &o e-- <br />City: �tl�Y� State: ()1, A Zip: /p0PO % <br />Mailing Address (if different): F& /S EAST01 ELL 1904� _ <br />City: C vL// ��T state: 'WA Zip: <br />Email:�oK _ r^o�oc�LQCOIvtc:c{ t. i�erPhone: (�D�n -J clJ "off/J <br />Total Cost to Install Device (from contractor invoice): 5 <br />1, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at the above referercud property address be made payable to, and <br />sent to, the vendor specified on the back of this forr,�. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. 1 will not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the completed•Backwaler Prevention Device rebate packet by the City of Everett <br />Owner <br />Date <br />