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00 Backwater Prevention Device Rebate Program <br />L Vendor Payment Option Form <br />Project Number. _ __ (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: —Jbx.—/ <br />Installation Address: <br />City:Stater <br />Mailing Address (if different): <br />City: <br />State <br />Email: <br />Total Cost to Install Device (from contractor invoice): 5 <br />Phone: W-)�7o-6/ <br />Cq4-31-8d' <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 />1 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 />roval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />app <br />Signatur�oror <br />tyOwner <br />1Li7-!� <br />Date <br />