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Backwater Prev��ntion Device Rebate Program <br />Vendor Payment Option Fo�rm <br />Projecl Number. (Ciry fo P�vide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Ovmer Name: 1t if LL( F�c1�1 �. M l�-i.G'� <br />Ins:allation.lddress: 3113 �i� ST � <br />City: �l'��� State: �� Zip:. .�Zv I <br />Mailing Address (if differentJ: � ��'E <br />City: State: Zip: <br />Email: <br />Total Cost to Install Device (lrom contractor invoice): $ <br />Phone: ( ) <br />I, the properly owner, request to have the City of Everetl Backwaier Prevention Device rebate check <br />for tho installation of lhe device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this (orm. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. I vdill not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of lhe rebate to thc vendor does not exemp[ me from Backwater <br />Prevenlion Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor lisled on lhe back of Ihis form pending <br />approval o( lhe completed Backwaler Prevenlion Device rebate packet by lhe City of Everett <br />i <br />/� � �2. /'��i� Zz J w.. �s <br />w <br />Signature of Property Owner Date <br />