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� Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: _ (Cify to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: � <br /> Property Owner Name: 1 ��i ✓''� Wl�,' �_� — <br /> � <br /> ' InstallationAddress: -��� :{ � ��� � — <br /> City:�1)C'. C' 1 _State: (,U)r Zip: ���n � <br /> Idailing.Address(if dilferent): <br /> City: Slale: Zip: <br /> Email: lAY'SL�I F��iH r 1� << � s�, Corn Phone: ( � </�-S_�.1 Z�/��7 <br /> Total Cosl to Install Device (/rom contractor invoice): 5 �`1Q �' 3� <br /> I, the•properly owner,.request lo have the City of Everetl Back�vater Prevenlion Device rebate check <br /> for Ihe installalion of the device al the above referenced property address be made payable to, and <br /> sent to, the vendor spacified'ondheback ot this form. By requesling lhe rebate check be made <br /> payable lo the vendor, I ayrec lo the following: <br /> 1. I will not receive a rebate check direcUy irom Ihe Cily of[verell. <br /> 2. Assigning payment of thc rebale lo the vendor does nol exempt me.from Backwater <br /> Prevention Device Rebate Program requirements. <br /> I aulhonze the release o(my rebate to ihe vendor listed on the 6ack of this form pending <br /> approval of the compleled Backwater Prevention Device rebate packel by the City of Everetl <br /> C—___] <br /> 3 � r:Y( � ,C <br /> Signature of Properly ON:ner Dale <br />