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Backwater Prevention Device <br /> RQbate Program <br /> For intemal Use: Pr ject Number. � <br /> i <br /> Vendor Paymerit Option Form� <br /> Please complete both sides of the form <br /> Property Owner Section (pleasc print): ' <br /> —__,.�1'�myh 1 v��s an , <br /> Pr( bperty Ovener_Naine y�` <br /> _ // 3 1=,�14��- U l�!/�� � J�o/L> <br /> Propefly Addressj <br /> C_-_ -_ LY1 S�e C7iP� <br /> �Alt'ernate'Mailing A`�dcl-r�ss Ly� � S�ta�,e Lpi <br /> '�`�..��- 3>-�`� t n. �' C"o �, <br /> I'� hone Finail <br /> I, the'.Property Owner, request to have the City of Evelett Backwater Prevention Dedice <br /> rebate check for the installalion referenced at the Property Address be made payable <br /> to, and senl lo, lhe Vendor. By requesting the incentiv�/rebate check be made payable <br /> to the Vendor, I agree to the (ollowing: <br /> 1. I �roill not receive a Backwater Prevention Device rebate check directly from the <br /> City of f_verett. <br /> 2. ; Assic�ning payment of the Back��ater PreveNio I Device rebate to the Vendor <br /> � does not exempt me (rorn Backwater Prevention Device Rebate Program <br /> , requirements. , <br /> I �w�horize the release of my rebate to the Vendor hsted on page two of this form <br /> pend�iny approvnl of lhe completer; lackwaler Prevenlion Device rebate package by <br /> the City ot Everett <br /> I <br /> i <br /> �/-��--,_ _ .I-- -- I � � _X/–�_—__ <br /> ✓ � <br /> (Sgnafu�ebfl;roj���ty�Owner� I Date � ` <br /> : _ � � � <br /> � <br /> ; � <br /> ; , <br /> � <br /> Revisedl9(3/2014 Page 1 of 2 <br /> � , <br />