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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: (City to Provide) <br />Please complete both sides o# the form <br />Proper�y Owner Section: <br />Property Owner Name: <br />� � �� c�� �c. � <br />City: ������� State: W� ZiP... `� �� f <br />��� <br />Instaliation Address <br />Mailing Address (if differenf): <br />City: <br />State: <br />Zip: <br />� i�� �t . ( ��-�� � �� ` �'�� <br />Emaif: �t`� � ���i� 1��. � ' � Phone� <br />To�al Cost to I nstall Device {from contractvr invoice): $�� `'(�.� �°�� <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 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 Pragram requirements. <br />I autharize the release of my rebate to #he vendor lis#ed on the back af this form pending <br />appraval of the completed Backwater Pr�vention Device rebate packet by the City of Everett <br />C <br />Signature af <br />� / � f �� <br />Date <br />