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���� Backwater Preventlon DeviCe Rebate Program <br />Vendor Payment Option Form <br />Project Number _ (Clty fo Pr�vlde) <br />Pleaae eomplete both nides of the form <br />Properly OwnFr Seetion: <br />Property Owner IJame: _ C�f��. �V�iiQY <br />Inelallation Atlanass� ��2 � �V G�J.'t �fVe+MJ� <br />ciy �veel� s���e: \..�e�• z�P. °��s'2 d\ <br />Meiling Addraee (il dillbrenl): <br />Ciry: Stete: 2ip: <br />Emall: CAl\v+��+ St0��11'�Zf�h►.�`M __ Pnone:�C) ZLZ V�� S <br />`s� � , S�c <br />Total Cosl to Inetall Devi.e (Irom tontrocfor invoice). 5 24�a <br />I, Ihe property owner, requaet lo heva lhe Cly ..; Ev�rett Beckwater Preventlon Devlce rebata check <br />tor the inatelh �tlon of ihe device al 11ic ebove referanced property addreaa be made payable to, and <br />eant to, l�a vendor epncified on Ihe back of Ihla form. By raqueatmg Ihe iebele check bo made <br />payeble lo lhe vendor. I apiee to the following: <br />1. I wlll not receive a rabatu check direUiy from Ihe City o1 EvereN. <br />2. As�lgninp peymenl of the rebate lo the vendor doea not ezempl me Irom Beekweter <br />Prevenfion Devfce Rebate Progrem requiromenta. <br />I authonze Ihe rclease of my rebate to Ihe vendor lieled on t�e back ot th�a iorm pendinq <br />app�ovel ol lhe completed Beckwetei Prevenllon Devlce rabale peckel by I�a f,lry of Evorott <br />Sipnalure ot Propetty Owne � Oate \ <br />