Laserfiche WebLink
� Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (City to Provid?) <br /> Please complete both sides of the form <br /> Prope�ty Owner Section: ; <br /> Property Owner Name I'U1F �� �n�� <br /> Installation Address: <br /> City: t'l�-�/Y� State: � '�Zip: q�(��. <br /> MaiiingAddress(i/diRerent): �ID(0^ �n��/"� /V�u <br /> City: 1 [,Q.CLI.CI�_ State:�_Zip: � d �.�� <br /> Email:�� C�[ li'!J � /1bYV1 Phone:� �;��D�P�fi <br /> Total Cost lo Install Device (from contractor invorce): $ <br /> I,the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at the above referenced property address be made payable to, and <br /> sent to, lhe vendor specitied on lhe back of this torm. By requesting the rebate check be made <br /> payable to the ven�nr, I agree to the followi�g: <br /> 1. I will not receive a rebate check direclly from the City of Everett. <br /> 2. Assigning payment o(thi�rebate to the vendor does not exempt me from Backwater <br /> Prevenlion Device Rebale Program requirements. <br /> i authorize the release of my rebate to the vendor listed on the back of this form pending <br /> approval oF the completed Backwater Prevention Device rebate packet by ihe City of Everett <br /> 1 �fJ /d-� / ' <br /> Signature of Pro rty Owner Date <br />