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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: (City fo Provide) <br />Please compleie bo#h sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />lnstallation Address: <br />City: �__.-1 )1�'l�.�" State: __���' t `_. Zip: � � <br />Mailing Address {if different): <br />City� <br />S#ate: <br />Email: Phone; ��7 � `�` �� <br />Total Cost to Install Device (from contractorinvoice): $ �`"�� ��� <br />1, the property owner, request to have the City o# Everett Backwater Prevention Device rebate check <br />for the instaHation of ihe device ai the above referenced property address be made payab[e ta, and <br />sent 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 the following: <br />1. I will not receiv� a rebate check directly from the City of Everett. <br />Assigning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />2. <br />I authorize the refease of my rebate #o the vendor listed on the bacic of this form pending <br />appraval of the completed Backwater Preven#ion Device rebate packet by the City of Everett <br />�`:rv�..— : .,�''Y�G� <br />Signature of Property C?wner <br />Date <br />