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� <br />Backwat�r Prevention Device <br />Rebate Program <br />Fer inters�al Use: Project Number. <br />Vendor F�ayment Optio� f=orm <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />JUL1C ��fCc�( <br />Proper�ty Owner Name <br />:.( G 1 D / -7 `+'- ,� <br />Property Address <br />Alternate Mailing Address <br />�f 2,_5 -.3d 3 - U7�"G.� <br />Phone <br />City <br />City <br />Email <br />State Zip <br />State Zip <br />�roL, cL��.n <br />i, the Property Owner, request to have the City of Everett Backwater Prevention Device <br />i ebate check for the installation referenced at the Property Address be made payable <br />to, and sent lo, the Vendor. By requesting ihe incentive/rebate check be made payable <br />to thc Vendor, I agree to the follo�ving: <br />1. I will not receive a Backwater Prevention Device rebate check directly from the <br />City of Everett. <br />2. Assigning payment of the Backwaler Prevention Device rebate to the Vendor <br />does not exempt me (rom Backwater Prevention Deeice Rebate Proyram <br />requirements. <br />I aulhorize the release of my rebate to the Vendor listed on page two of this form <br />pending app�oval of the completed Backwater Prevention Device rebate package by <br />the Ciry r` �verett <br />�� <br />1� c.�� �'Jl� <br />Siynal re o�Properiy Owner <br />Revised 913/2014 <br />;'.: �`�-,zal �l <br />Datc <br />Page 1 of 2 <br />