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U <br />Backwater Prevention Device Rebate Program <br />. Vendor Payment Option Form <br />Projecl Number: - - -_ (Clty to ProvldeJ - <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O��mer Name: � � < <� Q.1'V1 �II�Q �e{���UQ <br />Instauationjddress: CIIZ �u.G�(.e.t� � _ <br />City: ��%Qi�'Ti�1' _ State: ��i . Zlp: � 0 O �� <br />Mailing Address (ildiHe2nt): <br />City: <br />Email:� <br />State: <br />Total Cost to In;tall Device (Irom contracforinvoice): 5 <br />Phone:.( ) <br />I, the property owner, request to have lhe City of Everetl 8ackwater PreventiomDevice rebate check <br />for tlie inslallalion�of the device at the above referenced property address be made payable to, and <br />sent to, ihe vendor specified�on the back of Ihis fortn. By requesting the rebate check be made <br />payable to lhe vendor, I agree to the following: <br />1. I wiG not recaive a rebate check direclly from lhe City of Everett. <br />2. Assigning;paymenl of the rebate lo the vendor does not exempt me from Backwatcr <br />Prevention Device Rebate Program requiremenls. <br />I authorize the release of�my rebate to the vendor listed on the hack o( this form pending <br />approvai of Ihe completed Backwaler Prevention Device rebale packet by lhe City of Everetl <br />� <br />Slgnature of•Property Owner <br />