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�Backwater Prevention Device Rebate Program <br />rr Vendor Payment Option Form <br />Prc jed Number: ______ (��ty ro Provide) <br />Please com�lete both sides of the form; <br />Property Owner Section: <br />PropertyOwnerName: .S�'�vc'.'� ��<i v�i7.� iJ II9oi'il-�- <br />Inslallafion Address: Z� Q J�'� �`` S'' <br />city: �✓'-�'-i'�-- State: 1i✓:i 2ip:�� I <br />Mailing Address (il diNerentJ: <br />City:_ State: Zfp: <br />Email: _ <br />Phone:( ) �'�yd� <br />1 otal Cosl to Install Oevice (Irom confracfor invoice): $ 2�l ��� 39 <br />I, the propeRy owner, request to have lhe City of Everetl Backwater Ptevention Device rebate check <br />for the inslallation of the devioe at lhe above reterenced property address be made payable to, and <br />sent lo, lhe vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the tollowing <br />1. I will nol receive a rebate check directly from the City of Everelt. <br />2. Assigning payment of the rebate lo the vendor does not ezempt me from Backwater <br />Prevention Device Re�ale Program requirements. <br />I aulhorize the release ol my rebate to Ihe vendor listed on the back of this fortn pending <br />approval of the compleled Backwaler Prevention Device rebate packel by the City oi Everett <br />�/��/� � <br />Signature of Property Owner <br />6-i7-1� <br />Date <br />