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Eiackwater Prevention aevice Rebate Program <br />Vendor Payment Option Form <br />Project Number. _ _ _ (Ci(y fo ProviUc) <br />Please complete both sides of the form <br />Property Owner Section: <br />'I Property Ovmer Name: /���'%`=- ���r/f.Yl� <br />li I�stallation Address; ..2/s'/ (.�rtiNLi4 - , G�P� . <br />Cily: !=(/P.YP � S�ale: l2l✓"I _ Zip: /g%�� <br />tilailing Address (if dilferent): ���^ ^�- <br />Cily: State ____ _ Zip: <br />i <br />/ <br />Email: �C� rd��ier� l�F���,v�f��n5r: r•!r_'� Phone: (�F�i) ?_�2 -S`1/G� <br />; Tolal Cost to Install Device (Irom confractor invoicr.): $ `-����``�*1___t1 l-L�—`��� <br />L- — -- - --- -- - ----- — <br />I, the property o��+ner, requesl to have lhe City oi �verett Backwater Frevention Device rebate check <br />for Uie inslallalion o( the device at lhe above referenced property ::•�dress be made payable fo, and <br />sent to, thn vendor specified on ihe back of this form. By requesOng the rabafe check be made <br />piyable tc, Jie vendor, I agree to the (olbwmg <br />1. I ti:�;�i nol receive a rebate check direclly from the City of Everett. <br />Z Assigning payment of Ihe rebate lo lhe vendor does nut exen�pt me (rom Backwater <br />Prevention Device Rebate Program requirements. <br />I authonce lhe release af my rebate to Ihe vendor hsted on lhe back ot ihis (orm pending <br />,�pproval of the campleted Back�valer Prevenlian Devicr. rebate packet by ihe City of Everett <br />/� � <br />/ /�fl,+c� i� L //�I t.2 �r- _ i�`S <br />L <br />Signalure of Property Owner Date <br />�--- - - - -- - -- ---- ----- ---- -- <br />