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� Backwater Prevention Qevice Rebate Program <br />Vendor Payment Option Form <br />Pro�ecl Number __________ (City fo Provide) <br />Ple�se complete both sides of the form <br />Property Owner Section: <br />Property Owner Name <br />r N�.. <br />Installation Address: 2'��� / ���� �� � Q 'av� <br />C�ty: __Cv e �e TT State: _ lv..�__Zip: $Le/ _ <br />Ivlailing Address (iI diHerent) _ _ _ _ �_ <br />Cily _ Slate: Zip�_ - _.— — <br />Email: _ Phone: K26} Z� = 3q.6� <br />Tolal Cost �o Inslall Device (from contrac(or invoiceJ: 5 2- � 5c3t+ . 6� <br />I, lheproperty o�vner, requec; to have the City o( Everetl Backwater Prevention Device re6ate check <br />(or the installation.of lhe device at the above referenced property address be made payable ro, and <br />senl lo, Ihe vendor specdied on the back of this fomi By requesting lhe rebale ciicck be made <br />payable lo lhe vendor, I agre� !o the following. <br />1. I will not receive a rebate cher.k directly (rom the City of EvereU. <br />2 Assigning payment of lhe rebate lo the vendor does not exempl me from I�ackwatcr <br />Prevention Device Rebate Program requiremenls. <br />� I aulhori�e Ihe release of my mbate lo Ihe vendor listud on lhe back of Ihis foim pendiny <br />i approval of thr. completed B>ick�valer Prevenlion �evice rebale packet by ihe City of Everell <br />«.cc/ � 4.vr C�._ <br />Signature o<� Ovmer <br />a 7 -�s <br />Date <br />