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Fackwater Prevention Device <br />Rebate Program <br />For intemal Usc: �roj�cl �hrnbor. <br />Vendor Payment t)ption Form <br />Please cnmplete both sides of the form <br />Property Owner Section (please print): <br />--- -- — -- -- _ _-- - -- <br />I- --- - <br />; _�u2r�i',i:"I�� -�--n ^�Tc�,.,w st��n <br />I Property O�:�ner Name � �--Y /��/��,� <br />I �� �1__VII)_C1w�A fivc_ I/����___L�—_—`I�VCrU __ <br />� Property Address � State Zip , <br />Alternafe fviaibng Address <br />�5- �2-223�-- <br />Phone <br />City <br />Email <br />State <br />I, the Propert�� Owner, request to have lhe City of Everell Backwater Prevenlion Device <br />rhate check (or the installation referenced at the Property Addro;; be made payable <br />to, and sent to, the Vendor. By requesting Ihe incentive/rebale check be made pay.�bl�� <br />ia thr. Vendor, I agree to lhe tcliav.ing: <br />1 I �vill not receive a E3ockwater Prevei„ion Device rebate check directly from tLi: <br />Cily of L=veretl <br />.- Assigning payment of ihe f3ack��,�ratr�r Picvention Device rehate to the Vcndor <br />does not exemp! nii� linm R;+cl<walei F-'i��vi:nhon I)i�vice Reb�tr. Propr,u�; <br />requiremen�s. <br />I authorizc tl�e rclea,e o( my rehrde to the Verdnr �;s(nd on pac�r, tv��o of this firm <br />pending approval o( Ihe compleled Back�vater f'revention Device n�b,�t�. par.koge by <br />the City of Everelt <br />�� <br />- �--� — - ���� - — ;3f �1�2c(��__ <br />_C� <br />�ti��natu�e ol Pa;prv�y (h:�nnr�' � rUate--. <br />I'2ue 1 r� 2 <br />R.u;�5:��9.,� i,J,�,; .. <br />