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� . � : � s � � �� <br />� :1� . � . ` *. �s, � .�'. �. ! .... <br />Ci i r: �..�. <br />� �:,, � ' ��� r, '�` '' . '�� : � '� <br />� <br />■ • � � � • � • ! ' <br />Please carnplefie bvth sides of the form <br />Property Owner Section: <br />Property Owner N�rr <br />Instal(ation Address: <br />City: __�� i2��.?� S#ate: _��'� Zip: �'`�a a% � <br />Mailing Acidress �rf a'itferentj: <br />Gity. <br />State: <br />� <br />Email: �. ��.'� YYl . � Phone: t�� t'a�i�'� �- �={ �'� a`"� <br />`iotal Cost to Instalf Device {from contractorinvoice): $_����3 ��s� <br />l, the property owner, request to have the City of Everett Backwater Preuention Device rebate check <br />for the instaliatian nf ihe device at the above referenced property address be rriade payable ta, and <br />sent to, the vendor specified on the back of #his form. By requesting the rebate check be made <br />payable to the vendor, I agree to the fiollowing: <br />I wilf not reeeive a rebate check d'+rectly fram the City of Everett. <br />2. Assigning payment of the rebate #o the vendor does not exernpt me fram Sackwater <br />Prevention Device Rebate Program requirements. <br />1 authorize the release af my rebate to the vendor listed c�n the back af this form pending <br />apprflval af the completed Bact�water Prevention Davice rebate packet 6y the City of Everett <br />Si�nature of Praperky Owner <br />� � � � � �--- <br />Date <br />