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• • I <br /> Backwater Prevention Device <br /> `��t-�� R�bate Program <br /> ; <br /> For internal Use: Project Number: <br /> i — <br /> Ven�or F'a�ment Qption �orr�j <br /> � - <br /> Please complete both sides of the form <br /> i <br /> Property Ovvner Section (please print): I <br /> ; �/ � � <br /> =Jcu.�..s H<<.1:.tr' � <br /> �Property0wnei-N ma�: ' <br /> .2 3 i�l 2 S — .s� �,.�r-�" i (.,l/ i��.r� I <br /> [Prop'.PrtyAddre"ss� tCityr`.%� ;�State�"`� —"'' ' <br /> Zip= <br /> � <br /> Alteinate�4aili�n Add�ess j <br /> C 9 City='" State.-�--- Zip;�. <br /> � <br /> _ �/2 � - /�3 - 0.l;� i�w, �l Uie�kc� �e��. e� e . cor�. <br /> ��ne iFinail�- � <br /> � <br /> � <br /> i � <br /> I, the Properry Owner, ;equest to have the City o( Eve�ett Backwater Prevention Device <br /> rebate check for the installation referenced at the Property Address be made payable <br /> lo, and sent to, the Vendor. By requesting the incentivie/rebate check be made payable <br /> to the Vendor, I ayree lo the (ollowing: <br /> 1. I will not receive a Back��dater Prevention Device rebate chec!� directly from the <br /> Ciry of Everett. I <br /> 2. Assigning payment ci the E3ackwater Prevenlioii Device rebate to lhe Vendor <br /> does ��ot exempt me from 6ackwater Prevention Device Rebate Prograrn <br /> requirements. � <br /> � <br /> I aulhorize the release of my rebate tc ' ^ ,endor listed on page lwo of this form <br /> pending approval of the completed Backwater Prevention Device rebate packaye bV <br /> the Ciry o(Everett j <br /> i <br /> � /J � <br /> �i,,.�-.-,�� 1Y,4,/.�-- � �{• � �.'� 5 <br /> � <br /> 3ig ature'of.Property.Owner i 'Date� <br /> � � _. <br /> i <br /> I Page 1 �f 2 <br /> Revised 9/3/201A <br />