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� Backwater Prevention Device <br /> � Rebate Program <br /> For internal Use: Project Number: <br /> Vendor Payment Option Form <br /> Please complete both sides of the form <br /> Property,Ovuner Section (please print): <br /> �c�.ndacc. L. Carsm-� -- <br /> f?ropertyOwner•Name� <br /> V=-�'72�8'2�cke✓ ia�re- �aerett �n/A �$ZD � <br /> �Pioperty_Address+ �Cllya ,Stale-� tZipa <br /> --��� <br /> Altemtite"Wiailing•Aiid;ess"_ ��� (City� cSl`ale� Zi <br /> wP� <br /> �+zS 7Sq Z.�s3 Cec�-rson � msn . com <br /> Ph��nc-'J �Email-� <br /> I, lhe Property Owner, request to have Ihe City of Everett Rackwater Prevention Device <br /> rebate check for the installation referenced at the PropeRy Address be made payable <br /> to, arid sentto, fhe Vendor. By requesting the inr,entive/rebate check be made payable <br /> to the Vendor, I agree to ihe following: <br /> 1. I will not receive a 13ackvoater Prevention Device rebale check direr.tiy from fhe <br /> City of Everett <br /> ? Assiyniiiy payment oi lhe 13ar,kv✓ater Prevention Device rebate to ihe Vendor <br /> does.not exempt me trom 13ackwater Prevenlion Device Rebatc Proyram <br /> requirements. <br /> i aiithorize,thc release oi my rebate lo Ihe Vendor listed on page tvdo of ihis (orm <br /> pendin�3 approval of the compleled dackwater Prevention Device rebafe par.kagc by <br /> the Cily o( Everetf <br /> _.��(ctec. _�. G.uan- 7 iy�,� <br /> ----- —� --- -- <br /> Signnfurc:oI•l;ropc�iy.l�wnu�-.y �7f, <br /> 1���- � <br /> Rr.visr.d,9!?./2D14 �'apc 1 ot 2 <br />