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� <br /> � � Backwater Prevention Device Rebate Program <br /> ' Vendor Payment Option Form <br /> , Project Numbec �!/�//�Z /�S (City fo ProvideJ <br /> I <br /> � <br /> Please complete both sides of the form <br /> � Property Owner Section: <br /> � <br /> � — /---- - - <br /> Property Owner Name: W��I- ��� �i�f�'S �iv�G�et <br /> I InstallalionAddress: /L�"D �i�G��li /�✓� <br /> ! City: ��v�[�'� State:_�(�Zip:�g�I <br /> Mailing Address (if dillerent): <br /> I <br /> � City: Stale: Zip: <br /> ' EmaiC ov�L��o�>_.s.��-�v4�w�..����,uwi Phone: (�ZSf ��7�'�`� � <br /> i <br /> To�al Cost lo Install Device(/rom confracforinvoiceJ: $ ���� _ <br /> i � <br /> I I, lhe propeAy o�vner,request to have the City of Everetl Backwater Prevention Device rebate check � <br /> ; tor the installation of the device at the above referenced property address be made payable to, and <br /> � sent to,lhe vendor specified on the back ot this fonn. By reques�ing the rebale check be made <br /> payable to ihe vendor, I agree to Ihe following: <br /> , 1. I will not receive a rebale check directly from Ihe City of Everelt. <br /> I2. Assigninc�payment of the rebate to the vendor does not exempt me fram Backwater <br /> i Prevention Device Rebate Program requirements. <br /> � <br /> I aulhorize the release of my rebale to Ihe vendor listed on the back o(this form pcnding <br /> approval of the completed Backwater prevention Device rebale packel by Ihe City of Everetl <br /> � <br /> I <br /> '���1�.��-G��1 Zz <br /> I Signature of Property Owner Dale <br /> � <br /> 1 <br /> � � <br />