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�� <br />Backwater Prevention Device <br />Rebate Program <br />For internal Use: Project Numbor. <br />Vendlor Paym�nt Option Form <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />. <br />Property Address City Stale Lip <br />Altemate Mailing Address <br />�27-,Z5"9 -7oG3 <br />Phone <br />w.� <br />Email <br />St2te <br />0 <br />I, the Property O�vner, reyuest to have the City of Everett Backwater Prevention Device <br />rebate check ior the installation referenced at the Property Address be made payable <br />to, and sent lo, the Vendor. Ry requesting the incentive/rebate check be made payable <br />to the Vendor, I agree to the following: <br />1. I will not �eceive a Backwater Prevention Device rebate check direcUy from the <br />Cily o( Evr,retl. <br />2. Assigning p�yment of the Backwaler Prevention Device rebate to the Vendor <br />does not exempt me from Backwater Prevention Devi� � Rebate Program <br />requirements. <br />I authorize the release of my rebate to the Vendor lislecf on page hvo of Uiis form` <br />pending approval of the completed f3ack�vater Prevention pevicc rebate package by <br />lhe City of Everell <br />Sigroaiure oi Property Owner <br />Revised 913l2014 <br />Date <br />Page 1 of 2 <br />