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Project htumber. <br />�ackwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />(City to Provide) <br />Ptease complete bo#h sides of the form <br />Property Owner Section: <br />; .� <br />Proper#y Qwner Name: � � � � � ���� ��,� � <br />Instaflation Address: � � f � !"'( c, ,�;�,�� �� (�-v�-e. <br />�— <br />City: <br />Mailing Address (if different}; <br />Gity: <br />Email: <br />S#a#e: <br />State: <br />Total Cost to Install Device (from contractorinvoice): $ <br />Zip: <br />Zip: <br />_ Phone: ( ) � <br />�.��•� <br />I, the property owner, reques# to have the City of Everett Beckwater Prevention Device rebate check <br />#or the insfal(ation of the device at the above referenced property address be made payable to, and <br />seni 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 tFte foliowing: <br />1. I will not receive a rebate check directly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does nof exempt me #rom Backwater <br />Prevention Device Rebate Program requirements. <br />i authorize the release of my rebate to ihe vendor listed an the back of this form pe�ding <br />approval of the compfeted Backwater Prevention Device rebate packet by the City of Everet# <br />Signature of Property Owner <br />� <br />� �,� <br />Date <br />