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1 <br /> , <br /> I <br /> � <br /> Backwater Prevention Device � <br /> Rebate Program i <br /> I <br /> � <br /> For intemal Use: Project Number. � <br /> i <br /> Vendor Payment Option Forrn :' <br /> i <br /> Please complete both sides of the form I <br /> Prope�ty Owner Section (please print): i <br /> � <br /> i <br /> � � <br /> �- '', �' S'1��� �D <br /> Property Owner Nar P� , <br /> i � 1 '"1 l��s�1 �;no �'�� l.��1 �g�f <br /> Property Address Cily State Zip � <br /> i <br /> Alternate Mailin i�ddress City Stale Zip <br /> -�S• �'�.9>9a. _ <br /> Phone Email <br /> i <br /> I, the Property Owner, request to have the Cily of Everett Ba�kwater Prevention Device <br /> rebate check for lhe installation referenced at the Property Address be made payable ; <br /> io, and sent to, the Vendor. By requesting the incentivelrebate check be made payable <br /> to the Vendor, I agree to the iollowing: <br /> 7. I will nol receive a Backwater Prevention Device rebate check directly from the i <br /> City of Everett. 1 <br /> 2. �ssignin� payment of the Backwater Pruvention Device rebate to the Vendor <br /> does not exempt me irom Backwater Prevention Devic;e Rebate Program <br /> requirements. <br /> I autliorize the release of my rebate to the Vendor listed on page lwo oi this form � <br /> pending approval of the completed Backwater Prevention Device rebate package by � <br /> the City o(Everetl � <br /> I <br /> �-I �,,_� ; <br /> Signafure of Property wner Daf� j <br /> Pagc 1 of 2 <br /> Revised 9/312014 <br />