Laserfiche WebLink
4 Backwater Prevention Device Rebate Prograrn <br />Vendor Payment Option Form <br />Project Number _ (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Nam <br />Installation Address: <br />City: rrJrsfr f State: —01Zip: ' X %i0 1 <br />Mailing Address,(if different): <br />City: <br />State: <br />Email: G g •n G , �( Phone: (�iS$) k j — S :S S <br />Total Cost to Install Device (from contractor invoice): $ <br />I, 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 referenced property. address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor. Lagree 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 th¢ completed Backwater Prevention Device rebate packet by the City of Everett <br />of Property Owner <br />Dad <br />