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4 Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. <br />(City to Provide) <br />Please complete both sides of the form <br />Proparty Owner Section: <br />Property Owner Name: 9r 1 /A, Ecl i r _ <br />Instal'atlonAddress:: /%r?,- Vi' Ll rn;R ✓e <br />City: EverEQ _State:& —zip: -/8ZO/ <br />Mailing Address (if different): <br />City: <br />State: <br />Email: �r�/QhyK��l1LC' YA100. COIti Phone t�i Zr�Z—��/ <br />Total Cost to Install Device (from contractor invoice): $ <br />I, the property owner, request to have the City of Everett Backwater Prevention Device rebata check <br />for the Installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendor. I agree to the following: <br />1. 1 wiJ not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the completed Backwater Prevention Device rvbato packet by the City of Everett <br />q / 15 <br />Signature of Prop y Owner Date <br />