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Backwater Prevention Device Rebate Progr�m <br /> Vendor Payment Option Form <br /> Project Number. (Ciry to Provide) <br /> Please complete botn sides of the form <br /> Property Ownar Section: <br /> Prope�ly Owner Name: ^-�-� j ��n�-.�'d-d� �I`-fal—�— Y �� <br /> Inslallation Address: ��t�'` g / � �� <br /> City: ��� State: �v"`�-- Zip: �P� f <br /> Mailing Address(iI diflerent): <br /> City: State: _Zip: <br /> Email: Phone: ( ) <br /> Tolal Cost to Install Device (/rom conlractor invoice): $��\. Li� <br /> I, the property owner, requesl to have'the Ciry of Ev,;rett Backwaler Prevention Device rebate check <br /> for the installation of the device at the above referenced property address be made payable to, and <br /> sent to, lhe vendor speci(ied on the back of this forrn. By requesting the rebate check be made <br /> payable to the vendor, I agrea to lhe following: <br /> 1. I will not receive a rebate check directly from the Cily of EvereQ. <br /> 2. Assigning payment o(ihe rebate to Ihe vendor does not exempt me from Backwater <br /> Prevention Device Rebale Program requirements. <br /> �I authorize the release of my rebate lo the vendor lisled on �he back of this form pending <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> ;/ <br /> �-P � �, � Iz� <br /> ure of Property Own L`���e <br />