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! <br /> , <br /> Backwa'r.er Prevention Device <br /> � Rebate Program <br /> For internal Use: Project t�'u�ni;er ___ <br /> Vend�r P,�yment Option Form <br /> Please complete hoth sides of the form <br /> Property Owner Section (please print): <br /> _S��F GA-���-�;,D -- — <br /> Properly Ormer Name <br /> _/`/�z ���;��� <br /> Property Address City S1ate Zip <br /> Altemale Niai'ing Address / City State Zip <br /> `1Zsr'�57� .7/(Q <br /> Phone [mail ` <br /> I, the Property O�vr•er, request to have the City of Everett Back�vater Prevention Device <br /> rebate check for the insiallation referenced at the Property Flddress be made payable <br /> to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br /> to the Vendor, I agree to the following <br /> ' 1. I �vill not receive a Backwaler PreveMion Device rebate check directly'from the <br /> City of EveretL <br /> � 2. Assigning payment of the Backwater Prevention Device rebate to the Vendor <br /> ' does not exempl me from Backwaler Prevenlion Device Febate Program <br /> - requirements. <br /> I authorize the release oF my rebate to thc Vendnr listed on page I�vo of this form <br /> pending approval of the completed Backv✓ater Prevention' Device rebate package by <br /> the City o(Everett <br /> _ v{��l-Q�W�.l.'.�/1—�!S V �\ �l — – -- 1 '� ( Ti � S _ <br /> , � <br /> Signature o`Property Owner � . D3fe <br /> - , t: , <br /> Page 1 of 2 •. <br /> Revised 9I311014 <br /> '" \ <br /> .� �\. l <br />