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� <br />� <br />Backwater Prev�ntion Device <br />Rebate Pragram <br />For internal Use: Proj�_ ' i��mher: <br />Vendor Payment Optian Form <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />Pro� rty 03er Na� e� <br />� �7 <br />Property Address <br />Allernate Mailing Address <br />�a�-- �.,.,�o - �sr� <br />Phone <br />City <br />Email <br />State Zip <br />State Zip <br />I, the Property Owner, request lo have the Ciry of Everett Backwater Prevention Device <br />rebate check for the installation referenced at lhe Property Address be made payable <br />to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br />to the Vendor, I agree to the following: <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 Backwater Prevention Device rebate to the Venclor <br />does not exempt me from Backwater Prevention Device Rebate Prc�ram <br />requirements. <br />I authorize lhe release of my rebate to the Vendor listed on page two of this fomi <br />pending approval of the completed Backwaler Prevention Device rebale package by <br />the City of Everett <br />Signature of Property O�n�ner <br />Date <br />Page 1 of 2 <br />Revised 9/3/2014 <br />