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OLRack aWF Prevention Devive Rebate P QWml <br />Vendor Payment OpIdon F on <br />Project Number. (City to Provide) <br />pteas- complete P oth sides eti the ffol7r: <br />Proppft O.imer Section: <br />Property Oa -timer Nam <br />Installation Address: l l V.' r `_C I., <br />City: 4 : - f �{ . stab: C .. ��'( ZiP:. <br />Mailing Address (if drileranl): <br />City: <br />State: zip, <br />Ema l: Phcne: tOv. i ')cJ 7 <br />I <br />J <br />Total Cost to install Device (from contrar forinvoice): $ yU ��' c <br />1, the property' oartc;; --�ueat to have the City of Everett Backwater Prevention Device rebate check <br />for the Installation of the device at tfte above referenced property address be made payable to, and <br />sent to, the vendor specifies on the back of this form. By requsstigg the rebid-- ciecic be made <br />payable to the vendor, I agree b the following: <br />i. 1 will not receive a rebate check directly from the City of Everett. <br />2 Assigning payment of the rebate b the vendor does not exempt me from Bacarrater <br />Prevention Device Rebate Program requirements. <br />1 authorize hhe release of n'y rebatr to the vendor listed on the back of this forth pending <br />approvai of the completed Backwater Prevention Device rebate packet by the City of Everett <br />Signature of Property 0vrner Date <br />