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Backwater Preventicn De��ice Rebat� Program <br />c,� Vendor Payment Option Form <br />Projecl Numbec _ (Cit, fo Pro��ide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Nam <br />Installation Address: <br />City (:V��(1' <br />��lailing Address (ildiNerenf): <br />City: <br />State: _�,�_ Zip:����� <br />Sfale __ <br />Email IA�.�7i �,GQ_e,i'�.j?��'i(��4r1�Y. Y�� Phone: (��� �a��, l�1SS�� <br />_`�„"` �1' J <br />Total Cost to Install Device (l�om contractor invoice): S _ <br />I, ihe property o�vner, request lo have the Cily o( Everetl Backwaler Prevenlion Device rebate check <br />(or lhe inslallalion of the device at lhe above referen ;ed property address be made payable to, and <br />senl to, the vendor specified on the back of tlns form. By' requesling the rebate cheek be made <br />payable to the vendor, I agree lo the follo�ving: <br />1. I will not receive a rebate r.heck directly Irom the Ciry of Everetl. <br />2. Assigning paymenl of the rebate to Ihe vendor does not exempt me (rom Backti�ater <br />Prevenhon Device Rebate Program requiremenls. <br />I aulhorize lhe relcase of my rebate to the vendor listed on thc back of this form pending <br />approval o( the compleled Back�vater Prevenlion Device rebale packei by Ihe City of [verett <br />Si ture ( Property O�vner. <br />��y <br />Date <br />