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EY TT <br />Backwaiter Prevention Device <br />F:ebate Program <br />For internal Use: Pro�ect Numhr.i <br />Venr�or Payment Option Fc�rm <br />Please completc both sides of the form <br />Property Owner Section (please print): <br />- ----- ---------- -- — <br />(,fJ�� LG i �1nvi ul. �S�ti� <br />I Pro erty O�vrer Name <br />—�-71 i /1c�CK� �CL�E�2_ �`��E -- <br />i I'roperiy Address Cit/ Siate <br />� _�!-E /� — --- C�/ 14- <br />' �q�ma�e Ivlailing Add�ess City State <br />Phonr. Email <br />__ � � �_?5-�- Z9 <br />Zip <br />GI� 7G� — <br />Zip <br />� <br />�. tre f'roperty Ov,�ner, requesl to have the City of Everett Qackti�ater Prevention Device <br />r��hate check for the installation referenced at the Property Address be made payable <br />(<�, �3nd sent to, the Vendor. By requesting the incentive/rebate chec.k he niade pa,af,lc <br />tc� tl�e Vendor, I agree tn the (uliowing: <br />1. I will not receive a 13ackr�at�r PrevenGun Device rebate check direclly irom the <br />City o( Everett. <br />� Assi_yning payinent of the Backwater Prevention Device rebate to the Vendri <br />r1���s nr�t ex:'inp! nte fror.i C3ack�vai�r Prev�±Mion flavice R���hrile I�rugrani <br />r��yuiiements <br />I.iuthim?�-� th�� release �f my reba�e to �h�� Vien�;oi hsted un payc lwo oF lhis (orm <br />,u:ndin�a ,ipproval of th� coin�ilete�l 13;ickw,�ler Prcvr;ntion Device rebate �ack�iye b�, <br />th�. C:h,� of Cverett <br />� <br />� <br />. - �J�:��_ <�''�=�_ _ - <br />Siynatwe ni Prnpnrty O�:�ner <br />RFr�,;� :f p"�,,��.: <br />'��L`�----- <br />Dr�rc <br />Pagc 1 of 2 <br />