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Backwater Prevention Device <br />4MTr 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 />r 7'/ 01- <br />Property Owner Name <br />705 ZoZi2Uf. t_ vF/, e 241, 1. X <br />Property Address <br />City State <br />Zip <br />3�0z, cS G-eSch/ <br />/I cSenIf✓� l�M <br />Alternate Mailing Address <br />City State <br />k9r9/44 <br />Zip <br />Phone <br />Email <br />I, the Properly Owner, request to have the City of Everett Backwater Prevention Device <br />rebate check for the installation referenced at the Property Address be made payable <br />to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br />to the Vendor, I agree to the following: <br />1. I will not receive a Backwater Prevention Devine rebate check directly from the <br />City 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 release of my rebate to the Vendor listed on page two of this form <br />pending approval of the completed Backwater Prevention Device rebate package <br />the City of Everett l <br />Signature of Property Owner <br />Revised 9/312014 <br />Date <br />Page 1 of 2 <br />