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i <br /> Backwate�r Prevention Device <br /> � Rebate Program <br /> i <br /> ; For internal Use: Projecl Number, <br /> Ve�ndor Pay�mer�t Optio� Form <br /> _ _� <br /> . �� J � Please complete both sides of the form <br /> Property Owner Section (please print): <br /> �' �-��� --- 1 <br /> —�"-� � tL <br /> Property O�vner Na�m I <br /> �li'��- _�2-�/L'-7i����L �--���� .L,r�� y��� <br /> PropeCy Address City State Zip <br /> P,Iternate �lailing Address City •Stale ZiP <br /> �',�.�'���_l1�t'��Ci_----�i��;.sL�c�-�l ro�. <br /> Phone Finail <br /> i ---- — <br /> I, the IPruperty Owner, request to have the City oi Everett Backwater Pravention Qevice <br /> rehate check for the ins:allalion referenced at ihe Property Address be made payab�e <br /> to, an'd sent to, the Verdor. By requesting the incentive/rebate check te made payable <br /> to the;Vendar, I agree to the following: <br /> i <br /> 1.� I will not receive a Backwa;er Prevention Device rebate check directl�• from the <br /> � Cily of Fverett. <br /> 2. ' Assigning payment o� tne Backwater Prevention Device rebate to the Vendor <br /> I does not exempt me fr,�m Back�ti�ater Prevention Qevice Rebatc Program <br /> � <br /> j requi�emenis. <br /> i <br /> � <br /> I authorize the release of my rebalc to the Vendor listed on page two of this form <br /> pend�ing approvat of'the completed [3�ck�aater Prevenlion Device rebate package by <br /> U�e jity of Everori <br /> i � <br /> � I_'F���- _ Jr�� �Sr <br /> Si i�iatu're�/Prooei1y Owner Dafe <br /> i <br /> � <br /> I <br /> � <br /> Revisedi i13/20�4 Par�e 1 of 2 <br />