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� , <br />� <br />Project Number: <br />Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />(City to Provide) <br />Please complete both sides of the form <br />Properiy Owner Section: <br />Proper�y Owner Name; v�t`�,�. �- �:.. � w'� �.� <br />installation Address; <br />Cfty: <br />Mailing Address (if differenf): <br />City: <br />Email: <br />State: <br />State: <br />Total Cost to Install t�evice (from coniractorinvoice): $ <br />� <br />Phone: (L/-2,�) "��% S/�3 <br />I, the properky owner, request to have the City af Everett Backwater Prevention Device rebate check <br />for the instaliatian of the device at the above referenced proper�y address be made payable to, and <br />sent to, Yhe vendor specified on the back of this form. By requesting the rebate check �e made <br />payable to the vendor, 1 agree ta the foilowing� <br />1. 1 wilE not receive a rebate check directly from the City of Everett. <br />2. Assigning payrr�ent of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements_ <br />I authorize the reiease of my rebate to the �endar listed on fhe back of this #orm pending <br />approval of the campieted Backwater prevention Device rebate packet by the City of Everett <br />Signature of Property Owner <br />��2� � "��v <br />Date <br />