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Projecl Number: <br />Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />(Cily to Piovide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: JGi'1 Ll.� I L°I" I'(n ob I�� h <br />Installation Flddress: �30� �i (� I� I Q� w�� <br />City: EVCVP.'�"'� _ State: w/� _ Zip� et B�� � <br />Mailing Address (if di/lerent): <br />Cily: __ <br />EmaiC <br />Slate: <br />lbtal Cost to Pislall Device (from contraclor invoice) $ <br />Phone: ( ) <br />I, the properly owner, request to h�ve the City o! Everetl Backwaler Prevention Device rebate check <br />fnr the instailation of lhe device at the above referenced property address be made payable to, and <br />sent lu, ihe vendor specilieo on lhe back of lhis form. By requasling the rebale check be made <br />payable to Ihe vendor, I�gree to the followinc�: <br />1. I will not receive a rebale check dtreclly from Ihe Cily of [verell. <br />2 Assiyning paymenl of ihe rebate lo the vendor docs not exernpt me from [3ackwaler <br />Preve�lion Devicc Rebalc Pro�ram requirernenls. <br />I aulhorire Ihr, release of nry rebale to Ihe vendor fsled on Ihe bar.k of lhis fonn pending <br />approval of Uie compleled B��ckwaler Preveation Uevice rebate packel by ihe Cily c�f Gverett <br />--�i�����-----. <br />Signa�ure of Property Ovaner <br />— y /� �i � s <br />Dale <br />