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Backwater Prevention Device Rebate Program <br />00 rr Vendor Payment Option Farm <br />Project Number: <br />(City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: _5L� u - <br />Installation Address: 2 iu'r) 2 i,J 7rze h <br />City. /Gro r / State: t l Zip: 2y <br />Mailing Address (if different): 4 0. �S O <br />City: Staler✓ 4- Zip:-J5G <br />Email: /fL Sv hlc C2 <f Phone: <br />Total Cost to Install Device (from contractor invoice): $ _ A ' 3� C <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. I 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 />Z� 2-6 <br />Signature of Property Owner Date <br />