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�ackwater Prevention Device Rebate Program <br />Vendor Paymenfi Option Form <br />Project Number: (City to Provrde) <br />Please complete both sides of the form <br />Property Owner Sec#ion: <br />Property Owner Name: � ���r''a ��A "�" �''.��,- � �"���5'f <br />knstallation Address: �,� `� ���Ci,f�(� �� A%° � <br />City: � k��� - state: z�p: � �� �1 <br />Mailing Addr�ss (ifdifferenf): <br />City_ State: Z�P� <br />Emaii: �, l�°7C:e.�-�,'Ji 1`•�vl�t�t,t��l��)� �C�cYL Phone: (���) �r��- �� 1 4 <br />Total Cost to Install Device (from confractorinvoiceJ: $�� ��� — <br />I, the property owner, request to have the City of �vereit Backwater Prevention Device rebate check <br />#or the instaliafion of the device at ihe above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of ihis fiorm. By requesting the rebate check be made <br />payable to the vendor, i agres #o #he following: <br />I will not receive a rebafe check directiy from the City of �verett. <br />Assigning payment af the rebate to the vendor does not exempt me fr�m Backwater <br />Prevention Device Rebate Program requirements. <br />f authorize the reiease of my rebate to the vendar iisted on the back of this form pending <br />approval of #he completed Sackwafier Prevention Device rebate packet by the City of Everett <br />of Property Owner <br />� � <br />ate <br />