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Backwater Prevention Device <br />Rebate Program <br />For internal Use: Project Number: <br />Vendo�r �ayment Option Form <br />Please complete both sides of the form <br />Property ,Owner Section (please print): <br />PropertY OWner Name <br />Property Address <br />Alternate Mailing Address <br />City <br />Ciry <br />State Z�P <br />�� <br />State Z�P <br />`—t' Email <br />Phone <br />I, the Property Owner, request to have the City of Everett Backwater Prevention Device <br />rebate check for the installation fe f uesting the incenti elr�ebate check be made payable <br />to, and sent to, 4he Vendor. By Q <br />to the Vendor, I agree to the following: <br />1. I will not receive a Backwater Prevention Device rebate check directly from the <br />City of Everett. <br />2. Assigning payment of the Backwater Prevention Device rebate t� the Ven or <br />does not exempt me from Backwater Prevention Device Rebate Program <br />requirements. _ <br />I authorize the release of my rebate to the Vendor listed on page two of this torm <br />a roval of the completed Backwater Prevention Device rebate package by <br />�ending PP <br />the City of`Everett <br />� �- <br />Sianature of Property Owner <br />Revised 91312014 <br />�/-/A/� <br />Date <br />Page 1 of 2 <br />