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Backwater Prevention Device Rebate f'rogram <br />Vendor Payment Optfon Form <br />Project Number: ____ (City to Provide) <br />f'lease� complete both sides of the form <br />Pr�perty Owner Section; <br />PropertyO�vnerName: �n� ��'t��%-C,� /"I�l^�� ���i� <br />Inslallation Address' �� 0 �_.( �— � � <br />ciry:-�/-z� �� state:'�. <br />u2u/ <br />Mailing Address (ifdiKerent): I"f S I S 27 �� �{ / 1/iC - <br />1 ,�- �s�ss <br />City: ��� C�� C State: � Z�p <br />Email: G�,n7� S�� �/ �C�a��l �Ca�... Phone:�?,:-) �7%-�I:`�- v <br />Total Cost to Install Device ((rom contracforinvoice�: S <br />I, the property owner, request to have the City of Everztt Backwater 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, the vendor specified on the back o( this torm. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />I vdill not receive a rebate chedc direcUy from ihe Ciry of Everett. <br />2. Assigning payment o( the rebate �o the vendor does not exempt me from Backwater <br />Prevention Device Rebale Program requirernents. <br />I aulhorize the release of my rebate to the vendor listed on the back of !his form pending <br />approval of ihe completed Backwater Prevention Device rebate packet by the City of Everett <br />� 1'�.� <br />Signature of Property Owner <br />o-�i -1S <br />Date <br />