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� <br /> � <br /> i <br /> , , <br /> Backwater Prevention Device I <br /> Rebate Program '; <br /> For Intemal Use: Project Number: <br /> ( <br /> Vendor Payment Option Form � <br /> � <br /> Please complete both sides of the form ; <br /> Property Owner Section (please print): i <br /> � <br /> ; <br /> � <br /> P�ro�e�rty Own,:rName,� ` <br /> /7 Ta��an J eA/YX�/ � <br /> Propertyr�Address City [! State Zip � <br /> �7� O �O�i19�9x�P. �.?,�o.[�f G!/R.� p�L— ' <br /> Altemate Mailing Address City State Zip ! <br /> 7 rm�, ! <br /> Phone �Z�-as� ���7 Email � <br /> 1 <br /> i <br /> I, the Property Owner, request to have the City of Everelt Baokwaler Prevention Device � <br /> rebate check for the installation referenced at the Property Address be made payable � <br /> to, and sent to, the Vendur. By requesting lfie incentivelrebate check be made payable � <br /> to the Vendor, I agree to the following: � <br /> 1. I will not receive a Backwater Prevention Device rebate check directly from the ; <br /> City of Everett. � <br /> 7. Assigning payrnent of the Backwaler Prevention Device rebate to the Vendor � <br /> does not exempt me from Backwater Prevention Device Rebate Program � <br /> requirements. <br /> � <br /> I authorize the rclease of my rebaie to the Vendor listed on pac�e iwo of this form i <br /> pending approval of the completed Backwater Prevention Device rebate package by ! <br /> the City of�verett � <br /> � <br /> ���p � i <br /> �`q/J��4d��i — �d . ,./�f-- � <br /> Signature o�Property Owner Dafe ' <br /> i <br /> I <br /> f <br /> I <br /> Pegc 1 of 2 � <br /> Revised 9/3I2014 <br /> 1 <br /> 1 <br /> I <br /> � <br />