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� <br />>> <br />Backwater Prevention Device <br />Rebate Program <br />For intemal Use: Project Numbef: <br />Ve,ndor Payment Option Form <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />� <br />—�J.��'L� �D W �� <br />Preperty Owner Nam —' <br />--�-y--� w-��1�"�_ _"�—� C��P �t <br />Property Address Cii <br />� Y Stato <br />_1 � L� N'�c�i � sd�•� �J ��r�� (a, <br />Alfernate Niailir,g Address �i�y State <br />�` ..2.`i y �C'- ,��a��' ^ <br />_�=--- <br />Phone Email <br />7_ip <br />I, lhe Property Owner, reyuest to have the Ci,y 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. � will not reccive a E3ackwater Prevention Device reb;rte check directly from the <br />Ciry of [verett. <br />2. A:signing payment of thc Backwater Prevention Devir.e rebatc to thc Vendor <br />does not exempt me from �ackaeater Prevention Device Rebate Program <br />requiremenls. <br />i authorize the release of my rebate to the Vendor listed on page two of this form <br />pending approval of Ihu completed Hachwaler Prevention Device rebate package by <br />the City of Ev�retl <br />, • �, <br />I � :' �i <br />� �' -�/ /� .�l � . ; `.� <br />\,� <br />Signature o! Properiy Owner <br />Revised 9l3i20t4 <br />i `� <br />� ,.�` 7 <br />Dotc� <br />Page 1 of 2 <br />