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� Backwater Prevention De��ice Rebate Program <br />Vendor Payment f�ption Form <br />Project Numbec (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vner Name: rr �� �, <br />�.SK � <br />Installation Address: ?� G � `���I���� ' ` U� <br />City: l V��� State: 1N �- Zip:�.� I <br />Mailing Address (il diNe�enQ: ��� ` 1 V l�'r%'��� v I <br />City:l �I�� V, Stale: /rl1 _2ip: ����� — <br />EmaiC ����IVI�� `)1/I�v���,IC��`1��1t'/� COI`V) Phone:(�I� i0�1Z"����� <br />i <br />Total Cost to Inslall Device (Irom contractorinvoice): $��Sa �" <br />I, the properly owner, request lo have the City of Everelt Backwater Prevention Device rebate check <br />for the installation of lhe device at the above referenced property address be made payable to, and <br />sent to, the vendor specifed on the back of this form. By requesting lhe rebate check be made <br />payable to the vendor, I agree to Ihe following: <br />1. I will �ot receive a rebate check directly (rom the Cily of Everett. <br />2. Assigning payment ot the rebale to the vendor does nol exempl me from Backwaler <br />Prevention Device Rebale Program requiremenls. <br />I aulhorize the releasc of my rebate to Ihe vendor listed on lhe back of lhis fonn pendiny <br />approval of the compleled Hackwater Prevenlion Device rebate packet by the City of Everett <br />_ � <br />� <br />Signature of Property Owner <br />2.6 r�+A2 iS <br />Date <br />