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�-� <br />�r� <br />� <br />Backwater Prevention Device <br />Rebate Program <br />For internal Use: Project Number: <br />Vendo!r P'ayment Option Form <br />Please complete both sides of the form <br />P; operty Owner Section (please print): <br />L�� <br />Property Owner Nam.: <br />Property Address � City �! St.de <br />_� o �� U�rG�N�� ��� C ✓Crcit <br />Aitemate;Mailing Address Ciry State <br />Phone (� a 5 � 59 3 93 � Email �G <br />Zip C� gao I <br />$. f <br />Zip <br />I, the Property Owner, request to have the City of Everett Backwater Prevention Device <br />reb2?e cheok for ihe installation referenced at the Property Address be made payable <br />to, and sent to, the Vendor. By requesting the incentive/rebate ci��ck be made payab'; <br />to the Vendor, I agree to the following: <br />1. I will inot receivz a Backwater Prevention Device rebale check directly from the <br />City of Everett. <br />2. Assigning payment of the f3ackwater Prevention Device rebate to the 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 lwo of this form <br />Cending approvai of the completed Rackwater Prevention Device rebate packaye by <br />t'ie City of Everelt <br />' j���.b0.�-0. C. K�; n�e <br />Signature o(Property Owner <br />Revised 913/2014 <br />i I-�1-iy <br />Date <br />Page 1 of 2 <br />