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Backwater Prevention Device <br /> Rebate Program <br /> For internal Use: Project Number: <br /> Vendor Payment Option Form � <br /> Please complete both sides of the form j <br /> Property Owner Section (please print): � <br /> --- - -�-�C--l.�r l-� � �F Z�- � <br /> Property Uwner Name <br /> -- �3s'c QuCrC�c TFvc��2E'�1— V�A- �iP��+ � <br /> Property Address City State Zip . <br /> (s�z•w,�_ � <c��) <br /> Altemate Mailing Address City S[ate Zip <br /> �{ 25 33`�.vI�G d�c����� yq4r>,•c:�'v� � <br /> Phone Email � <br /> - --- --- -- - -- � <br /> s <br /> I, lhe Property O�vner, requesl to have Ihe City of Everelt Backwater Prevention Device ; <br /> rebate check for the instalialion referenced at the Property Address be made payable � <br /> to, and sent to, the Vendor. Ry requestinq the incentive/rebate check be made payable <br /> to the Vendnr, I agree to the follo�ving: <br /> 1. I��Jill not receive a [3ack�vater Prevention Device re6ate cher,k direcUy (rorn lhe <br /> Cih� of Gverett <br /> 2 Assigning paymenl of the Backwater Prevention Device rebate to the Vendor <br /> docs nol exempt me from [3ackwater f'revention Devioe Rebale Proyram <br /> requirements. 4 <br /> f <br /> I �wthorize the release of my rebate to the Vendor listed on page lwo o(this form � <br /> pending approval of the cornpleted E3ackwaler Prevenlion Device rebate pa�kage by � <br /> the City of E-verelt � <br /> i <br /> '���.�\,�..1 �: -.�`, ,�- �S�t��� <br /> , <br /> -- , ; <br /> Srgnalwe of Property Owi�er Dafe i <br /> I <br /> Page 1 af 2 <br /> Revised 9/3/2U 74 . I <br />