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�C <br />Sfia%Y\ "i <br />AW sackwater Prevention Device <br />�F ter- Rebate Pogram, <br />For internal Use: Project Number: <br />Vendor Payment Option Form <br />Please complete both sides of the form <br />Prape nr G%Nner Section (please print): <br />Pro�d{vner Name <br />p <br />A <br />/j L ,9 <br />�4�r <br />�ZZl0i 79f� <br />( Illy-.oln a <br />C. <br />1 <br />P�operty AddrCetil <br />�tt1 <br />City <br />1(- <br />rsv ter yl� 14� <br />Alternate Nailing Address <br />City <br />1i <br />Stale zip <br />C c'� <br />tiZr 1? Z 7 s7Y <br />iV• n���fcrak4Cn�c� <br />nct <br />Phone <br />Emd <br />I, the Property Oerner, request to have the City of Everett Backwater Prevention Device <br />rebate check for the installation referenced at the Property Address be made pryabie <br />to, and sent to, the Vendor. By requesting the incenlivefrebate check be made payable <br />to the Vendor, I agree to the following: <br />1. 1 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 to tie Vendor <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 form <br />pending approval of the completed Backwater Prevention Device rebate package by <br />the City of,Ev reef <br />i <br />i <br />/2 � COI <br />Signature of Property owner <br />Date <br />Page 1 of 2 <br />Revised 9/312014 <br />