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,,, , <br /> � Backwater Prevention Device Rebate Program <br /> ' Vendor Payment Option Form <br /> Project Number: (City fo Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: - <br /> Property Owner Name: /`7 ic haEl /� �!�/�� <br /> Installation Addrer: ! �D S �G/��E /T U` <br /> City: L ���/�-� _State:�_Zip: �p au/ ( <br /> Mailing Address(if di(lerent): <br /> City: State: Zip: <br /> emai�: �BWRA7'HpNF�j-iZ��1TIC2� �dk Phone: (�) o13a�' S'773 <br /> Total Cost lo Install Device(Irom confractorinvoice): $ �v ` �o �I <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,the vendor specified on the back of this form.By requesting the rebate check be made <br /> payable to the vendor, I agree to the tollowing: <br /> 1. I will not receive a rebate check direclly trom the City of Everett. <br /> 2. Assigning payment of;the rebate to the vendor does.not exempl me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> I authorize lhe 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 the City of Everett <br /> �/�� N� y,� <br /> Signature of Property Owner Date <br />