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� Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Number: _____ _ (Gty to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property O�vner Name:�L'.S E �_C /�1�5'0l1� <br /> Installation Address:_�(�__.���E � � � �i� �V� <br /> c�ty: �VCR,�7"y statP L(J� z�P: �v�?D/ _ <br /> hlailing Address(i(diNerent): <br /> City: State: Zip' <br /> Email�o ZA � � /kSN COM Phone: (y��� • ��d <br /> Total Cost lo install Device (6om confractor invoice): S_ <br /> I, the property owner, request to have the Cily of Everett Backwater Prevention Device rebale check <br /> for U�e installation of the device al the above reterenced property address be made payable to, and <br /> sent to, the vendor specified on Ihe back of this form By requesUng ihe rebate check be made <br /> payabie lo the vendor, I agree to the follow ng. <br /> 1. I �vill not receive a rebate check directly from the City of.EvereU. <br /> 2. Assigning payment o(the rebate to Ihe vendor does not exempt me trom Backwaler <br /> Prevenlion Device Rebale Pragram requiremenls <br /> I aulhorize lhe �elease of my rebate to U;e vendor listed on the back oi ihis form pending <br /> approval ol Ihe completed 8ack�vater PrevenUon Device rebale packet by lhe City o(Everett <br /> ' �.. �C,t„�-,� a -.�- a o �s <br /> Signature of Prdperty O�vner Date <br />