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� gackwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project NumSer: (Cify to Provide) <br /> Please complete both sides of 3he form <br /> Property Owner Section: <br /> Property Owner Name:� ��--a s �LC l P�r v� � <br /> Installation Address: ��-f v � �c/(�G a�- �..�c, <br /> City: �I.��/Gv, State: �✓�- Zip: � �v� <br /> Mailing Address�(i/diHerent): <br /> Cily: State: Zip: � <br /> Email:�l^'lCC�eCiV� �� �'^�'< < � ��``� Phone:�l2� ��J3SG.� <br /> Total Cosl to Inslall Device(from conlractor invoiceJ:$ �-� o Gr Y� <br /> I,the property owner,request to have the City of Everett Backwater Prevention Device rebale check <br /> for the installation of the�evice at the above referenced property address be made payable to, and <br /> sent to,the vendor specitied on the back of this form. By requesling the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will not receive a rebale check directiy from lhe City ot Everett. <br /> 2. Assigning payment of the rebate to�the vendor does not exempt me(rom Backwater <br /> Prevenlion Device Rebale Program requiremenls. <br /> Uaulhorize the release of my rebate to the•vendor lisled on lhe back of this torm pending <br /> approval�of the completed Backwaler Prevention Device rebate packet by the City of Everett <br /> �„ . �dU l�T�iY <br /> Si nature of Froperty Owner Date <br />