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�n� Backwa#er Prevention Device Rebate Program <br /> �w�T Vendor Payment Option Form <br /> �_J <br /> Pro�ecl Numbec ___ _ (City to ProvideJ <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> � �_ <br /> Property Owner Name: `Q�i�%���- �____ <br /> Installation Address: ���� � Ue�_�;��/�� • <br /> City:,���/j��State:_���Zip: � �� � <br /> t�4ailing Address(iI dilferent):._ _ _.____ <br /> City: _ State: Zip:. _ <br /> Email: Phone: ( ) <br /> Total �ost to Inslall Device (Irom contracforinvoice)� 5�.1� . � <br /> I,the property owner, requesl lo have lhe City of Everelt Back��,�aler Prevenlion Device rebate check <br /> for lhe installation o(the device at the above referenced property address be made payable to, and <br /> sent to, Ihe vendor specified on the back o(lhis form. By requesting the rebate check be made <br /> payabie to the vendor, I agree to ihe followinc� <br /> 1. I will not receive a rebate check directly from the Cily of Everett. <br /> 2 Assigniny payment of ihe rebate lo the vendor does not exempl me from Backwater <br /> Prevention Device Rebale Program requirements. <br /> I authorize Ihe releasc of my rebate to lhe vendor lisled on lhe back of this form pending <br /> approval of the completed Backwater Prevention Device rehate packet by the City oi Everett <br /> �� /� � <br /> ' (�f/�j/� -����''"-�'�1_. l'� '. /��/�/ <br /> Signature of Property Owner �f D te <br /> - ---- --� <br />