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Backwater Prevention Device <br /> Rebate Program <br /> For intemal Use: Pmject Number: _ <br /> Vendor Payment Option Form . � <br /> Please cumplete both sides of the form <br /> Property Owner Section (please print): � <br /> � � <br /> � �y14i4 � -- � <br /> Pro e y Ormer Name ., � <br /> —�325_ ��,—.-a.�e �I� �ve�-P1� 1,�� `tSIZ03 <br /> Pf��P.f}y ACICJfP.SS City State Zip , <br /> Alternate h9ailing Address Cily State Zip <br /> Phona Email <br /> I, lhe Nroperiy Owner, request to have the City of Everelt Backwater Prevention Device <br /> iebate check for the insla,lation referenced al the Property Address be made payable <br /> to, and sent to, the Vendor. By requesfing the incentive/rebate check be made payable <br /> to lhe Vendor, I agree to the following: <br /> 1. I H�ill not receive a Backw�ter Prevention Device ret�ate check directly from the <br /> Cily of Everett. <br /> ?. Assigning payment o(the Backwater Prevention Device ���bate to thr.. Vendor <br /> does not exempt me from Back����ater Prevention Device f2ebate Program <br /> «�quirements. <br /> I �uthorize the release of my rebate to Ihe \/endor listed on page two of this fom� <br /> pendiny approvai ni the completed Backwaler Prevenlion Device rebate packac�e by <br /> the City of Everetl � <br /> �. <br /> " -- _t� sllS <br /> Si9nature ol Property Owner Dafe <br /> Page 1 ot 2 <br /> Hevised 913/7014 <br />