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��%��Backwater Prevention Device Rebate Program <br />� Vendor Payment Option Form <br />PrCjArt N �'nC2r _____� _.. _�C� r tJ ��Ov,f,rn� <br />r�-ie85e wUiNidi6 uUii� �iut5 Oi iile iu�ni <br />Property Owner Section: <br />A <br />A <br />°rc��2�;�G,naf\�an'F �dr l9-'�{1h�.._�VO�I,�e'i�I —__. ____ <br />L} �/ i i <br />i <br />nsta lat�on n�+dress --h1-� - �CY..e.r—l{-vt.---- - <br />�,�%� ��)1� q-/)- o � <br />CiIS' �Sl�'L�itn _.,_ _ Slate �vi�_ _ �ip _ L�6 !� (____ <br />'.1a�iing Ah�7ress (d ddiBr=•�tl <br />0 <br />���Y _ .__..-- S!ate Z�o . <br />-- — ' ' --- ---..__ . ..-- � <br />��„z�� �ar�����nc e-fF�0.�(,�w� F�,��� ;zo6 �rs-3�Zz <br />� <br />Total Cas; !o insiali Devrz l+'cr., r.a�rrac;o� �nvo�ce) s�9. Sy-- -- ---- ------ <br />! Ih0 P�Op�rty c�wn�. requC$I �n hdv2'h� rit� o` E�;2rat' E32crtv�o!Ar VrEv. �liCn DBviCc •_b�'@ c�•'C4 <br />for Ihe instaltat�on of the oev�ce at !ne above referenced proGeny address be made payable �.o. a�tl <br />sa�! a tne vendor scecified on the �ack of th , form By ;zqueshnn Ihe rebate check b� ma-'� <br />;:r.}�3bie ic ihe �:cnder I�gree le'he;pllo�•nrg. v <br />� I v'tll �v)t r�;� cive ��Cbd'.� GheCk d:fe' ll�� (�OR1 Ih� C�Iy C� EV�if:ll <br />1 <br />i <br />1.�ssign�ng payrnent ot the rabate lo the ventlor does nct exempt .�A from °ack�vater <br />'revPntion Dev�ce Reoaie �'rogran'� requiremants <br />i aulhonze the rPiPase o' my rebare m;ne vennor I�;ted on tne nacx of �n�s torm perding i <br />anp�o��al ot the ccn,p�eted BacY.�vatei Prevenhon Dev�c� rGhate paCkel by 1',e C�ty o� Everetl <br />W� ci. __Lj���� <br />S,qnature o� Property Own�r Date , <br />