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�: <br />Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Numbe'r. <br />(Ciry to P�ovide) <br />� Please complete bofh sides of the form <br />Property Owner Section: <br />:,1.. . <br />: J;_. .`c;;, <br />. �G <br />f <br />Property Owner .Jame: �+ / t.CJ �f i'"!� u� ��/ � <br />Installation Address: �'1 � �1 �V � �� r `✓�� <br />City: _��L�.�-e._� _ State: (..�}�l Zip: �I d�Z D�� <br />Mailing Address (if diflerent): <br />City: S/tate: Zip: <br />�mai�: I�/A/!') �� )l VJdi7l'K!/� '�/�% �hone: ��`�'�`l`'�- � •3 <br />Total Cost to Install Device (/rom contracfor invoice): 5 � �� � <br />C� � c� <br />I, the propeAy owner, request to have the Ciry of Everett Backwater Prevention C�vice rebate check <br />for the instaliation of the device at the above referenced property address be ma, e payable to; and <br />sent lo, the vendor specified on the back of Ihis form. By requesling the rebate check be made <br />payabie lo the vendor, I agree to the following: <br />1. I will not receive a rebate check directly from lhe City oF Everett. <br />2. Assigning payrt enl of the rebate to the vendor does not exempt me from Backwater <br />Prevention Dew: e Rebate Progra reqwremen . ���j� �p�—E-/'1_Q� <br />I authorize the reiease of my rebate to the vendor listed on lhe back of this form pending <br />approval ot the completed Backwater Rrevention Devlce rebate packet by.the Ciry oi Everett <br />' G . <br />Signature oi Proparty Owner <br />_ ``_' / � /5 <br />Date <br />t J <br />! ; •, . ; '.. ....: <br />�;:: ,: . . <br />:, .. � • - <br />