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0;Backwater Prevention Device Rebate Program <br />V7 Vendor Payment Option Form <br />Project Number: <br />(City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: :HA ! ;1M/y;-:I. ryno Q L f�� [� IDIlYkI <br />Installation Address: <br />City: E tza izlL State: -10 AZip: <br />Mailing Address (if different): P,OJSO.� '4111 /} <br />City:11J1L_ffk— _ t�L State: _ A _ Zip: 990uC2 - ':�(l I <br />Email:-hatqAO- G-416I� CY_ <br />Total Cost to Install Device (from contractor invoice): S <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 Prokerjy Owner <br />Date <br />