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� Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Numbec (City to Provide) <br /> Please complete both sides of the form _ <br /> Property Owner Section: <br /> PropeAy Owner Name �a i ` �I �� n /� v C� <br /> � <br /> Installation Address 'Z 1�('� ��. ,^ �c/ U f' <br /> City: �y.�._�� }-j- State: w fl Zip: I � 0.2( <br /> Mailing Address,(d differenf): <br /> City: _ State: Zip: <br /> Email: Phone: ( ) <br /> G <br /> Total Cost to Install Device (/rom contracfor invoice): $ �'� � • � <br /> I the propeAy owner, request to have the City of Everett Backwater Prevenlion Device rebate check <br /> for lhe installalion of the devlce al the above referenced property address be made payabte to. and <br /> sent lo, the vendor speci(ied on the back of thi, form By requesting the rebate check be made <br /> paya6le to the vendor, I agree to Ihe lollowing: <br /> 1. I �vdl nol receive a rebate check dtrecUy from the City of Everell. <br /> 2. Assigning paymenl of lhe rebate lo the vendor does not exempl mc frorn Dackwater <br /> Prevention Device Rebate Program requiremenls. <br /> I authorize the release of my rebate to lhe vendor listed on the back of this fonn pending I <br /> ' approval of Ihe completed Backwater Prevention Device rebale packet by the Cily of Evereil <br /> �� l.J �/� i-� � <br /> Signature ot Property mSvner Date <br />