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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: <br />(Cify to Provide) <br />Please complete both sides of the form <br />Property Owner Section <br />Property Owner Name: �T��. �fj1C�N _ <br />Installation Address: �1 / V•�'�� f"T�� <br />City: �bf�[l State: �� Zip: �/�� / <br />Mailing Address (if diNerent): <br />Total Cost to Inctall Devrce ((rom conlrac(or invoice): S_���g - l�. <br />I, the property owner, requesl to have lhe City of Everett Backwater Preveniion Decice rebate check <br />for lhe installation of the device at the above referenced property address be made payabte lo, an� <br />sent to, the vendor specifie,i on the back of this torm. By requesting lhe rebale clieck be made <br />payable lo the vendor, I agiee to the follovring: <br />I will not receive a rebate check direcUy from lhe City of Everetl. <br />Assigning payment of Ihe rebale lo lhe vendor does nol exempt me trom Backwater <br />Prevention Device Rebate Program requiremenls. <br />I aulhorize the release of my rebate to the vendor lisled on the back oi this form pending <br />approval of the comple[ed Backwater Prevenlion Device rebate packet by thc City o( Everelt <br />���/ �� _ <br />-���� <br />Signalure oi Property Owner <br />�.D� .Zai ;� <br />