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Backwater Pre��ention Devi�e <br /> a' Rebate Program <br /> For internal Usc Project Number: <br /> VEndor Payment Opi�ion F�rm <br /> Please compsete both sides of the form <br /> Property Owner Section (please print): <br /> __�eVin �iv,p) �1-�n ivES�{-C�— -- <br /> .,.- ---z__==� <br /> �-- _r�j Uwner Name <br /> --��-D�-��-�_Ave_�vev�t� WI� q92oI <br /> �Picpiiity_Address ; �Cit , '... ' <br /> , .. Y ��e_:.. Zip�.t�- <br /> Al�crnate.A4dilinr.^AiidFc�s7 '��' <br /> ��.:�,�. :, -�: �ty �:.:: S;'aCe;:;% `a <br /> � •4+-Fb—Ici(� �Lj� Zip <br /> �---�-�_��2--� � VGS 1'"iA-1 -L <br /> �hoiie..'�- .Email• <br /> -------- t -- . <br /> I, ihe Preperty Owner, request to have lhe City of C-verett Bar.kwater Prevention Device <br /> rebate chech for the installation referenced at �he PropeRy Address be made payat�(e <br /> to, and s�nt to, the Vendor. By requesting the incentive/rebate check be made payabie <br /> In the Vendor, I agree to the fol�nwing: <br /> 1 I viill nol receive a f3ack��afer Prevention Devir,e rehate check direclfy from the <br /> City of Ever�tt. <br /> ? Assigning paymenl o(the Backwater Prevenlion Device rebate to the Vendor <br /> does not exempt me trom eackw�ler Prevenlion Device Rebale Proyram <br /> requirements. <br /> I autlinrize the release of iny rebate to the Vendor Ifsled on p.�gc hti�o o(this fontt <br /> penciing arpriiv,I nf the comrleled p;ir.kwater Pr�vention Device rebote package by <br /> the City of Lverett <br /> —�`� ��—�—� ----- _' I 7�i I�i <br /> CSIt}natu`rp.ol Propr.rty Owner=- - - � <br /> � �_Dalo <br /> Revi;ed 91:I201q Page 1 of 2 <br />