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O;Backwater Prevention Device Rebate Program <br />Wrr 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: '6CA¢-y-rA a Ix ))aa n <br />Installation Address: l,1 Poj vt__ <br />City: PR-e-f- State: Oft - Zip: qq';Zo1 <br />Mailing Address (if different): <br />City: <br />Email: <br />Stale: <br />Total Cost to Install Device (from contractor invoice): $ <br />Phone: ( ) <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 riot 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 />"A-- J&t-4j <br />5- 13-/5 <br />Signature of Property Owner Date <br />