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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: _ ___ (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Mailing Address (ildi(ferenfJ: <br />City: State: Zip: <br />Email:l IiJ 15C.1'� �l.�iV{��Itbn Phone:���r1'Y)"7� C�7a� <br />Total Cost to Install Device ((rom contracbr invoice): $���o / <br />I, the property owner, request to have the City of Everett Backwater Preverrcion Device rebate check <br />(or the installation of the device at the above referenced property address be made payable to, and <br />sent to, lhe vendor specifed on lhe back of this form. By requesting the rebate check be m.�de <br />payable to the vendor, I agree to the following: <br />1. i will not receive a rebate check directly from lhe City of Everett. <br />2. Assigning payment of the rebate lo the vendor docs nol exernpl tne from 8ack�vater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to ihe vendor listed on the back of this form pending <br />approval of the compleled Backwaler Prevention Device rebale packet by Ihe City of Fveretl <br />Signalure of roperty Owner <br />—16� '� <br />Date <br />