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Backwater Prevention Device <br />4--77 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 />.,id tI C ,Ic�e��ttaQ <br />Property Owner Name <br />I`1 A W A I v,v—A r✓E <br />p <br />�Jv.Ce� Wtt �li�ii� <br />Property Address <br />City State Zip <br />Alternate flailing Address <br />City State Zip <br />GJVG��Co.%d 11.1 _ <br />Phone <br />Email <br />I, the Property Owner, request to have the City of Everett Backwater Prevention Device <br />rebate check for the installation referenced at the Property Mdress 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. 1 will not receive a Backwater Prevention Device 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 by <br />the City of erett <br />';A/II <br />Signature of Property Owner Date <br />Page 1 of 2 <br />Revised 9/3/2014 <br />