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<br /> i� Backwater Prevention Device Rebate Program
<br /> Vendor Payment Option Form
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<br /> � -F.roject Number _'(Cilyto Prov,ide) .,; - '
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<br /> f , '' � � Please.complete 6oth sides ofthe form ;, t
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<br /> ' '�. Property Owner SectEon: ° '_`
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<br /> Property�Owrier:Name�L��� 2 fl !�? A G 2��'� cS�t�E/J $
<br /> I Installation Address � I� U 9 :.y�� �. � `
<br /> ' City:�UG2�TT ; State: LU/�)` ,' ZiP�--g �a-��__ ` �
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<br /> h9ailing Address (i(different): . /`/ / � —�� �" sT � '
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<br /> . City��U�J�t,/� ' S`tate: L-��1 ,' Zip: 9 �Z0 / �
<br /> Email: `"� _ Pho��s a5� —o?7a y �
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<br /> Total Cost to Install Device (fiom contracforinvoica): S._ �
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<br /> i I, the property owner, request!o�have the City.of Everett Back�yater Prevention DEvice rebate cbeck ,
<br /> , for the installation of the device at the abobe referenced propertyaddress be.made payable to, and
<br /> sent to, the vendor speci(ied�on the back of this form:=By reques�ing the rebate check bemade , � ` .
<br /> - payable to the vendor;l agree,to the following.,' ' ' '' " ' ; `. •
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<br /> 1.. I will not receive a re6ate check directly from the City of Everett � � � +
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<br /> � 2 ' Assig�ing payment of the rebate to the vendor does not ex�mpt me:trom Backwater � '
<br /> i z 5 :.'; Prevention Device Rebate Program requirements. � �
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<br /> i I aulhorize the release of my rebate tolhe vendor listed on'Jh`e back,of thislforrim pendirc��, � � � ;i. �
<br /> k;:� t t;approval of Uie co;npleted Backv✓ater Prevention Device rebate packet by Ihe City of Everett I
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