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�Backwater Prevention Device Rebate Program <br />rr Vendor Payment Option Form <br />Project Number: (City to Provrde) <br />Please complete both sides of the form <br />Property Owner Section: ,. <br />Property Ov+ner Narr <br />Installation Address: <br />�ity; 1.Q%1–Q,r�—State: <br />Maiiing Address (il diHerent): <br />v��—z�P:__�'��r� � _ <br />City: _ State: Zip: <br />Email: `.�-_� ��✓t .��C7tir-, Phon�� �c� � U I Y <br />Tolal Cost lo Install Device (/rom contracbrinvoice): 5��, Se�or l <br />I <br />i I, the property owner, requesl lo have the City of Evere�t Backwater Prevention Device rebate check <br />� for lhe installalion of the device at lhe above referenced property address be made payable to, and <br />; senl to, lhe vendor specified on the back of this form. By requesling the rebate check be made <br />I payable to the vendor, I agree lo the tollowing <br />j <br />1. I will not receive a rebate check directty (rom lhe City of Everett. <br />2. Assigning payment of the rebate lo lhe vendor doe,•• not exempt me Irom 8ackwater <br />Prevention Device Rebate Program requiremenls. <br />I I aulhorice lhe release of my rebale lo lhe vendor listed on the back o( this form pending <br />japproval of the completcd Backwater Prevention Device rebate packel by Ihe City of 6verett <br />I ��� Z ����^- �L([�� �� <br />Signalure ot Property �wner Dale <br />