Laserfiche WebLink
, �i+ <br /> Backwater Prevention Device <br /> Rebate Program <br /> For internal Use: Project Number: <br /> Vendo�r F'aym�;nt Option Form <br /> Piease complete both sides of the form <br /> Property Owner SecYion (please print): <br /> �ZAti1 �ttl'f�1�l�U <br /> Piopgr�y qy,�ner f�jajr«u�� �� <br /> '7�� 1�t/ <br /> Pro rt Address City State Zip <br /> 1�11l- 99�2�1 <br /> �Iternat Mailing Address City State Zip <br /> -2��4Y7. - la-b4- <br /> hone � Email <br /> I, the Property Uwner, request to have the City of Everett Backwater Prevention Device <br /> rebate check for the installation referenced at the Property Address be made payable <br /> to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br /> to the Vend'or, I agree to the following: <br /> 1. I will;not receive a Backwater Prevention Device rebate check directly from the <br /> City of Eirerett. <br /> 2. Assigning payment of the Backwater Prevention Device rebate to the Ve�dor <br /> does not exempt me from Backwater Prevention Device Rebate Program <br /> requirements. <br /> I authorize the release of my rebate to the Vendor listed on page two of this form <br /> pending approval of the conipleted Backwater Prevention Device rebate package by <br /> the City of,Everett <br /> v' lI l7 ��`— <br /> Signature uf Property Owner Date <br /> Revised 9/3/2014 Page 1 of 2 <br />