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Backwater Prev ntion Device <br />Rebate Program <br />For internal Use: Poject Number: <br />Vehdor Payment Option Form I <br />Please complete both sides !of the form <br />Property Owner Section (please print): <br />a Address City. State <br />Zip <br />z cll Ong oats t ily n State; zip: <br />Email <br />I, the ,Property Owner, request to have the City of E <br />rebate check for the installation referenced at the F <br />to, an sent to, the Vendor. By requesting the incel <br />to the Vendor, I agree to the following: <br />1. I will not receive a Backwater Prevention De <br />City of Everett. <br />2. Assigning payment of the Backwater Preven <br />does not exempt me from Backwater Prever <br />requirements. <br />I autliorize the relPaso of my rebate to the Vendor <br />pen Jity <br />ng approval of the completed Backwater Pre <br />the of Everett <br />Of PropeRy Owner <br />Backwater Prevention Device <br />I Address be made payable <br />bate check be made payable <br />rebate check directly from the <br />Device rebate to the Vendor <br />Device Rebate Program <br />on page two of this form <br />n Device rebate package by <br />_5Z7 /` <br />Date., <br />Revisedi g/3/2014 <br />Page 1 <br />