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Backwater Prevention Device <br /> Rebate PrUgram <br /> For internal Use: Projed Number._ _._____ _ __ <br /> Vendor Payment Option Form <br /> Please complete both sides of the form <br /> Property Owner Section (please print): <br /> ��� 14-R-fLe"�U S�� --- <br /> Property Oyaner�Jame � <br /> 17�d lti?Z3`rl/�'�0(�E� �'W c�' __ __ <br /> Property�ddress City Slate 'Lip — � <br /> Altemate Mailing Address City Slate Zip , <br /> yZs' 7a �3- 7033 ----- --- --- I <br /> Phone Email � <br /> I, the Property O�vrer, request to have thc City ot Everetl f3ackwater Prevei��,.. Devir,c � <br /> rebate check for the insfallation referenced at the Property Address be made payable j <br /> to, and senl to, the Vendor. By requesting the incentive/rebale check be made payable � <br /> to the Vendor, I agree to the (olloading: <br /> i <br /> i. i will not receive a f3ackwater Prevention Device rebale check direclly fr��m (he � <br /> City of EveretL � <br /> '!_. , .;signing payment of Ihe f3ackwaler Prevenlion Device rebate lo Ihe Vendor <br /> does not exempl ine from [3ackwater Prr.venlion Device Ilehale Program <br /> reyuirernents. <br /> I aulhorizr, ihe release of my rebale to ihc Vendor listod on paye iwo o( ihis form <br /> pendiny approval oI ihe r.omplc�ted 13ackwater Prevention Device rebate: pacicage: by <br /> the City of Everetl <br /> �(�� � � <br /> —t_"""'_' � --- ------ ���fl��--- � <br /> Signafure oI Property Owner Dafe. I <br /> I <br /> i�,,�a� � or z � <br /> Revised 9/317014 � <br />