Laserfiche WebLink
4 Backwater Prevention Device Rebate Program <br />Zrr 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::: Y I q <br />Installation Address: C `� (r; t I +� S f _ <br />City:�Q l State: Zip: <br />Mailing Address (if different). <br />City: <br />State: Zip:._` <br />Email: r11� P— e; C_VY� t� SS Phone: (�iu) <br />Total Cost to Install Device (from contractor invoice): 5 <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 />Date <br />Signature of er <br />