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Backwater Prevention Device Rebate Program <br />Vendor Payment Uption Form <br />Project Number: (Cfty to Provide} <br />Please comple#e both sides of the form <br />Properly Owner Section: <br />Property �wner Name: �J1�'- VV���" 1����� a l! <br />Installafiion Address: �� �� �-0 �b <br />City: ��2.(�� S#ate: , <br />� <br />z�p: �� �� � <br />Mailing Address (if different}: r � � �"t ��� � ��� — <br />City: L�C��2 ���.V��� State: � Zip: ��� �S � .� <br />` �- � � �-�- <br />Email: C,�`�'�� ��C �� c`.t���J ^ 1 \ � i�(1� Phone: (�'�} �� � — <br />Tota! Cost to Instal[ Device (from contractor invoicej: $ ����� — <br />i, the proPerty owner, reguest t� have the City of Everett Backwater i'revention Devics rebate check <br />for ihe insfiailation of the device at the above referenced properLy address be made payable to, and <br />sent to, #he vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendar, ! agree to the following: <br />1. 1 will not receive a rebate check directly from the City af Evere�t, <br />2. Assigning payment af t�e reba#e to the vendor does not exempt me firom 8ackwater <br />Preventidn Device Rebaie Program requirements. <br />1�Uthofize tE�e rele�se of my rebate to the vendor iEsted on the back af this form pending <br />approval of the compieted Backwater Prevention Device rebate packet by the City of Everett <br />Signature af Property Owner <br />� -��-���/� <br />Date <br />