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Backwater Prevention Device Rebate Program <br />(4L <br />Vendor Payment Option Form <br />Project Number: (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: t Gil 6L . 'ZZ�S '\ C V` S ea t' S <br />Installation Address: °t \ � �-� h S+ <br />city: F v { r r- � � State: L�J •6 zip: al B a <br />Mailing Address (if different): <br />City: ,, ff State: _ Zip: <br />Email•.Ny0.0.run i*%-'it.C-UVVI Phone: polp lto5-0141 <br />Total Cost to Install Device (from contractor invoice): S > (n 0 3 . toy _ <br />I, the property owner, request to have the City of Everett 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 of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. 1 will not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />Signature of Property Owner Date `/I <br />