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� Backwater Prevention Device <br /> a Rebate Program <br /> For internal Use: Project Number: <br /> Vendor Payment Option Form <br /> F'lease compiete hoth sides of the form <br /> Property O�vner Section (please print): <br /> fD �� � IV� �Se l�- <br /> Property Owner nte ��� /� <br /> --� ��'f(_' r UQ '���—In i__�i__t. ��IS�C 9-� <br /> Properly Address Ci�y State Zip <br /> Altemate Mailing Address City State Z�P <br /> __72�-.�LD�S_�"� J n� w1 � M D�ti-1u1��II..�+• Y1 � <br /> Phone Email <br /> I, the Property Owner, request to have tlie City of Everett Rackwater Prevention Device <br /> rebale check for the installation referenced al the Property Address be made payable <br /> to, and sent �o, the Vendor. By requesting the incenlivelrehate check be made payable <br /> to the Vendor, I agree to the follovding: <br /> 1. i v�ill not receive a Backwater Prevention Device rebale check directly from ihe <br /> Cily of Fverett. <br /> 2. Assigninc� payment of the Backwater Prevention Device rebale to the Vendor <br /> does not c:xempt mr� irom Dackwater Prevention Device Rebate Program <br /> requirements. <br /> 1 aulhorite the release of my rebate to lhe Vendor listed on paqe lwo of this form <br /> pending approvai o( Ilie complrled Dackwater Prevenlion Device rebale package hy <br /> the City of Everett <br /> ��(����e�= -�-�y=/�— <br /> S g ofure of Property Ownor Dafr. <br /> �� <br /> Rcvised 91212p1� Paqc 1 of 2 <br />