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�4 Backwater Prevention Device Rebate Program <br />> Vendor Payment Option Form <br />F''U;ud Nurruor - — - ��;,� I:1',;:.J. ; <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />Installation Address: <br />City:'CieState: Zip:_��ZV <br />Mailing Address (if different): <br />City: <br />Stale: <br />Email: An OL 4 n w Mrw. �,tdn't Phone: (Ud)) '1W —OtW I <br />Total Cost to Install Device (from contractor invoice): s 2 Li 3 1 • t _ <br />I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device at.the above refe!enced 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 will not receive a rebate check di,ec!ly 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 />approvalrof the completed Backwater Prevention Device rebate packet by the City of Everett <br />[i1. t tI <br />Signature of Property Owner <br />3/2u�ZJI� <br />Date <br />