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:,-.,, <br />Backwa4er Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. <br />(Cily to Provide) <br />Please complete both sides of the form. � <br />Property Owner Section: <br />Property Owner Name: <br />Instailation Address: <br />City: <br />State: �� <br />MallingAddress (HdlHeren�): �y C )1 IV �aC.a�l'�1 �► - =+'lv,..� v�u� ��,i, <br />City:,�Yl{�f1J� Sfate:WV"� Lp:����� <br />Emeil; �(1('1Yli��'�D� �� ` •COr%1Phone:l✓it�l -J�t �'ZID� <br />Total Cosi to Install Device (hom confraclor�nwrce): $ �(1 i� <br />I, the pruperty owner, request to have ihe City of Everett Backwaler Prevention Devtce rebate check <br />for the inatallation of the device at the above referenced property eddress be made payable to, and <br />sent lo, ihe vendor specified on the back of this fortn. By requesling the rebate d)ack be made <br />payable to ihe vendw, 1 epree W Ihe foltowing: <br />1. I will not receive a rebate chedc directly irom the City of Everetl <br />2. Assigning payment of the rebale tA the vendor does not exempt me irom Backwater <br />Preventlon Devloe Rebate Program requirements. <br />I aul►wrize the retease of my rehate to the vendor listed on the back of this form pending <br />epproval ot lhe complete� Badcwater PrevenUon Device rebate packet by Ihe Cfty oi Everett <br />_ �� <br />Date <br />