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Backwater Prevention DeviGe <br />Rebate Program <br />For internal Use: Projecl Number: <br />Vendor Payment Option Form <br />Please complete both sides of tY�:: .'orm <br />Prnperty Owner Section (please print): <br />f, L`ia Property Owner, request lo have the City of Everett Backwater Prevenlion Device <br />rebate check for the installation referenced at the Property Address be made payable <br />to, and senl to, the Vendor. By requesting the incentive/rebate check be made pr.yable <br />to the Vendor, I agree to the foll�wing: <br />1. I will not receive a Backwater Prevention Device rebale check directly from the <br />City of Everett. <br />?_. Assigr�ing payment of the Backwater Prevention Device rebate to [he Vendor <br />does not exempt me irom Backwater Prevention Device Rebale Program <br />requirements. <br />I authorize the release of my rebate to the Vendor listed on pagc two of lhis (orm <br />pending approval of the completed Backwater Prevention Device rebale package by <br />tne City of Everett <br />_ iZ 2 Z J �- <br />' na re o(Property Owner Date <br />Page t of 2 <br />Revised 9I312014 <br />