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E <br /> Backwater Prevention Device <br /> Ey Rebate Program <br /> Far internal Use: Project Number. __ <br /> Vendor Payment Option Forrn <br /> Please complete both sides of the form <br /> Property Owner Section (please print): <br /> O�G UI�`J b�I�� ���'� <br /> Property O�vner Name��/� // �. /` — <br /> c iE� � <br /> Property Address City S�ate Zip <br /> Altemate t�4ailing Address City State Zip <br /> Phone Emaii <br /> I, the Property Owner, request lo have the City of Everett f3ackwater Prevention Device � <br /> rebate check for the installation referenced al tne Property Address be made payable � <br /> to, and sent to, the Vendor. By requesting lhe incentive/rebaie checic he made payable I <br /> to lhe Vendor, I agree to the follouiinc�: � <br /> 1. I wili not receive a Backwater Prevention Device rebale check direclly frnm the ` <br /> City of Everetl. <br /> 2. Assigning paymenl of lhe Backwafer Prevention Device rebate lo the Vendor <br /> does not exempt me irom Backa�aler Prevenlion Device Rebale Prugram <br /> requiremenis. <br /> I au(horize the release of my rebatr: to thc Vendor listed on paye lwo of this form <br /> pendinc� approval of the compleled Bar,kwater Prevenlion Device rebate package by <br /> the City of Everetl <br /> �,� �,/L� _ __ ____ _ � -I�0-I`� —_ <br /> Signature of Proper�y Owner Date <br /> I'agr. 1 0(2 <br /> Ilevi;ed 9/3/2014 <br />