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i <br /> � <br /> Backwater�Prevention Device <br /> �' Rebate P�ogram <br /> ' i <br /> , <br /> For internai Use: Pr,oject Number: <br /> Ver�clor Payment Option Form <br /> � <br /> I Plcase complete both sides lof the form <br /> Property Owner Section (please print): � <br /> ----- -- i <br /> ;---- <br /> � --��.-.-.-11+�i'L� I -- <br /> Property Ovmer Nmn� ' — -- <br /> -- aL3L_ ,���-N���, ff�e �' ; =-��_ <br /> Property Address City ' State <br /> 7ip <br /> 1?�le_���_.��-���� ��_�� wf�- qd'�58 <br /> Al�emate tvlailinc� Address Ciry � Stale <br /> I Zip <br /> -�1`-i51.�9�3 L�--1�-'�-�n�,e��.Gu�. Cr/!�'I <br /> — Phone—'— ----- Email i <br /> I _ — <br /> I, the Property Owner, request to have the City of [ve�ett Backwater Prevention Device <br /> rebate check (or the�installatie;i referenced at the Property Address be made payable <br /> to, and sent to, Ihe Vendor. By reyuesting ihe incentive/rebale check be made payabie <br /> to the Vendor, I a,yrre lo the following: <br /> 1. I will nol receive a Rackwater Preventinn Device rebate check directly from lhr <br /> Cily o(Lverett. <br /> 2. Assigning payment of ihe Qa�kwater Preventiori Devir.e rebate to the Vendor <br /> docs not exempt me from Bar.kwater Prevention Device Rebate Pmgram <br /> requiremen(s.' � <br /> I autharizc thc relcase of rny rebate lo the Vendor listed on pnge two of lhis form '' <br /> pendinr� approval oi the completed Ciackwaler Prever�tion Device rrbate p.�ckage by <br /> the City of Everefl <br /> � <br /> � <br /> `J�=�-����11/_ _ —y�K-1 S-- <br /> Sig��aturo oll'�aperfy Owne� � Uate <br /> � <br /> � <br /> Reviscd 913/701A ; P�r�e 1 of Z <br /> I <br />