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Backwater Prevention Device <br />Rebate Program <br />For internal Use: Project Number: <br />Vendor Payment Option Form <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />i-h1�en E <br />Property Address <br />Alternate Mailing Address <br />Phone <br />V �� <br />City <br />Email <br />State Zip <br />Slate Zip <br />v�. olearu(�.r <br />I, the Property Owner, request to have the City of Everett Backwater Prevention Device <br />rebate check for the installation referenced at �P-� Property Address be made payable <br />to, and sent to, the Vendor. By requesting the i��centivelrebate check be made payable <br />to the Vendor, I agree to the following: <br />t. I will not receive a Backwater Prevention Device rebate check directly from the <br />Ciry of Everett. <br />2. Assigning payment of the Backwater Prevention Device rebate to the Vendor <br />does not exempt me from Backwater Prevention Device Rebate Program <br />requirements. <br />I authorize the rclease of my rebate to the Vendor listed on page two of ttiis form <br />pending approval of the completed Backwater Prevention Device rebate package by <br />the Ciry of Everett <br />�.� a �� ^ <br />Signature of Property Owner <br />io a� <br />Date <br />Page 1 of 2 <br />Revised 9/3/20ta <br />