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Backwater Prevention Device Rebate Program <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� <br />Installation Address: ��Q 7 ���_� S � <br />City: _�/_�_�-�� State� Zip:_ <br />MailingAddress(ildi/ferent): c�o?�-i z(o� �y.0 Ti"f ,�-i/� �� <br />City: �/�jfJ�[Q� Sfate: W�}- Zip: �/ �U Z�J <br />Email: 'i��i I[,�q����C_L�1�'—tt�_L�O_�_ Phone: (f�J�� 3� g <br />Total Cost to Install Device (Irom confractor invoice): $ <br />I, the property owner, request to have the City of Everett Backwater Prevenlion Device rebate check <br />for the installa�ion of the device at the above referenced property address 6e made payable to, and <br />senl to, lhe vendor specified on fhe back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. I will nol receive a rebale chzck direclly from the City of Everett. <br />2. Assigning payment of the rrbate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program reyuirements. <br />I aulhorize Ihe release of rny rebale to the vendor listed on the back of lhis (orm pending <br />approval of �he wmpleted Dackv�ajg�Prevention Device rebate packet by the City of Everelt <br />Signalure of Property Owner <br />� Z �J <br />Date <br />