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� Backwater Prevention. Device Rebate Progrr�m <br />V'endor Payment Option Form <br />Project Number: (Cify to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: ic! Ac�. (� A.Sk � <br />Installation Ac!oreys: �/ Z� � �/���F' �� <br />City: E r/6R E 1r _ State: �N � Zip: /�'lo ( <br />Mailing Address (ildillerenf): <br />City: <br />Email: <br />State: <br />Phone: ( <br />Total Cost lo Install Device ((rom contracforinvoice): $ �Q ��. �ri <br />I, the property owner, request lo have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device al the above retere�iced property address be made pnyable to, and <br />sent to, the vendor specitied on 1he back of lhis form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. I will not receive a rebale check direcUy frorr; the Cily of Everett. <br />2. Assigning payment of the rebate lo lha vendor does not exempt me ftom Backwater <br />Prevention Device Rebate Program requiremenls. <br />I aulhorize the release of my rebate lo lhe vendor listed on lhe back of Ihis form pending <br />approval of the compleled Backwater Prevention Device rebate packet by lhe City of Everett <br />��t� � '��iJ(/���' — <br />Signalure ot Property Owner <br />!�� /�-/y <br />Date <br />