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Backwater Prevention Device <br /> d Rebate Program <br /> For internal Use: Project Number: <br /> Vendor Paymenf Option Form . <br /> Please complete both sides of the form <br /> Property Owner Section �, ,ease print): <br /> �-- — -- <br /> 1 r�vt /Le���- i <br /> Property Owner Nam� 1 (Y� �/ � <br /> 3]�I� -a�l � � � . �����,�` L�.�I� � I <br /> � <br /> �rnperty AJdress ' � City State Zip � <br /> �-�.Id� ����sa,+,-rx�rl�ol����t���,c.�_ 1.� 9'�C�� � i <br /> Allemate �ailing AdHress Ci�y State Zip i <br /> r_ 2>.� � c�� � <br /> Phone �mail ; <br /> --- — - - ' <br /> t <br /> i, the Property Owner, reyuest to have fhe Ciiy of Everett Backwater Prevention Device <br /> rebate check for the �nstallation referenced at the Property Address be rtiade payable i I <br /> to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable i <br /> to the Vendor, I agree to the following: i <br /> I <br /> 1. I will not receive a Backwater Prevention Device rebate check directly from the <br /> City of Everett. <br /> 2. Assigninc� paymeni of ihe Backwater Prevention Device rebate to the Venc+or <br /> does not exempt me irom Back�vater Prevention Device Rebate Program <br /> requirements. I <br /> I auihorize the release of rny rebale to the Vendor listed on page iwo of this forrt; <br /> pending approval of the completed Backuiater Preven;ion Device rebate package by <br /> the City of Everett <br /> I .--- <br /> i� ; � <br /> .4-C�/jN�.�'/J S,� J�.� � S <br /> �� <br /> r nature of Pruperty O�vn�r Date <br /> Page 1 of 2 <br /> Revised 9/3/2014 <br /> � <br />