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Backwater Prevention Device <br />Orr Rebate Program <br />For internal Use: Project Number: <br />Vendor Payment Option Form <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />Property Owner Name <br />Property Address City State Zip <br />Alternate Mailing Address City State Zip <br />Phone En iI <br />I, the Property Owner, request to have the City of Everett Backwater Prevention Device <br />rebate check for the installation referenced at the 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 Vendor <br />does not exempt me from Backwater Prevention Device Rebate Program <br />requirements. <br />I authorize the release of my rebate to the Vendor listed on page two of this form <br />pending approval of the completed Backwater Prevention Device rebate package b <br />the City of Everett <br />'All <br />Signature of Property Owner <br />Revised 9/3/2014 <br />I <br />I <br />Date <br />Pagel of 2 <br />