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� Back�rvaRer Preventicyn V�eviceRebate Prograrr <br />Vendor Payment Opti��n Form <br />Project �lumher. (City to Provid�) <br />Please complete Goth sides of the ;orm <br />Property Owner Section: <br />Property Owner Name: __4c <br />Installation Address: 2� �� <br />c�iy: E�ca.��r <br />. E. �6 <br />�/� (ZG. i r�R �N�E. <br />Slale: W � <br />Mailing P.ddress (If different): 110bG `TV`� � �"6� <br />g82�f <br />��, <br />City: ���""'� State: �� Zip: �gvZ'J <br />Email: ada�..eG3��@ k.�'�wQ�I��.� Phone:(�O�} el"`I • iYf4 <br />Total Cost to Install Device (lrom confractoNnvolce): S_ <br />I, the property owner, requesl lo have lhe City of Everelt Backwaler Provenllon Device rebale check <br />for Ihe inslallation of the device at the above referenced property address ho made payable to, and <br />sanl lo, Ihe vendor specified on Uie back of Ihis fonn. By requesting the rebate check be maAe <br />payable to Ih� vendor, I agree to the follo�ving: <br />1. I will not recelve a robate check direr,Uy irom th� City o( Everelt. <br />7.. Assiyning payment ot the rebale to the vendor does not exempl me from Backwater <br />Prevontion Device Rebate Program requirements. <br />I aulhorize Qie release of my rebalo to tho vondor Ilsled on Ihe back of ihls torm pendin� <br />approval of the completed Backwaler Prevenllon Devics rebate packel by Ilie Cily ot Everelt <br />Sipnature of Property Owner <br />���r�� <br />Dale <br />