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� Backwater Prevention Device Rebate Pr�gram <br />Vendor Payment Option Form <br />Projecl Number. (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�Nner Name: <br />Installalion Address: _(,���_ ��� � i " "` <br />Cily:�/1.�� Slate: �� <br />Mailing Address (il diHerent): <br />City• <br />State. <br />Email� Phone:�� =��3 <br />O <br />Total Cosl to Install Device (frorn confraclorinvoiceJ: 5��� �• <br />I, lhe property owner, reyuesl to have Ihe Cily o( Everelt E3ackwater Prevention Device rebate check <br />for the installation ot lhe device at Ihe above referenced property address be made payable to, and <br />sent to, the vendor speci(ied on lhe back of this form. By requcsting the rebale check be made <br />payahlc to the vendor, I agree to lhe following: <br />1 I wil! not receive a rebate check direcUy from lhe City of Everelt. <br />7. Assignin� payment ol Ihe rebate lo Ihe vendor does nol exempl me frorn Backwater <br />Prevenlion Device Rebale Program reyuiremen�s. <br />I au�hcrize the release ot my rebale to lhe vendor listed on Ihe back n( this fonn pending <br />approval of lhe rompleted Bar.kwater Prevention Device rebale packel by Ihe Cily of Everelt <br />Signature of Property Owner <br />.2 3 I 1- <br />alC <br />