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�^%�� Backwater Prevention Device Rebate Prograrn <br />Vendor Payment Option Form <br />Project Number. _____ (City to PrcvideJ <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vner tJam <br />Instailation �ddress�. <br />CitY: � \�?;^P � State: �_�_ Z'P �-�c�C�—� <br />Mailing Address (ildiKerenl): <br />Ciry' <br />State: <br />Email: Phone: (�1�) �J,.�'=��� <br />Total Cost to Install Device (/rom confractorim�oice): 5 a4-�,��.p_ <br />I, the property owner, request to have the City o( Everett Backwater Prevention Device rehate check <br />for the installa�ion of the device at the above referenced property address be made payable ro, and <br />sent to, lhe vendor specified on the back of this form. 6y requesiing the rebate check be made <br />payable lo the vendor, I agree to lhe following: <br />1. I will nol receive a rebate check direc0y Irom the City o( Everetl. <br />2. Assigning payment of the rebale to the vendor does not exempt me from Backwater <br />Prevention Device Rebale Program requiremonts. <br />I aulhorize the release of my rebate lo lhe �. endor listed on the back ol lhis form pending <br />aoproval of the completed Backwater Prevention Device rebate packet by the Ciry of Everett <br />1r` ��� (� ``��� <br />Signature of Property Owner Date <br />