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Backwater Prevention Device Rebate Program <br />Vendor Paymen# Option Forrr� <br />Project Number: <br />{City to Providej <br />Please complete both sides of the form <br />Property �wner Section: <br />Froperty Owner Name: <br />Installation Address ��� `'� � �,�.Q_�� • <br />City: ���,�,�' State: Zip: �o�C_7� <br />Mailing Address (if differeni): <br />City: <br />Email: <br />State: <br />Zip: <br />Phane: {�`o�� ��c� " � �C� <br />Totai Cast to Instafl Device (from contractor invoice}: $ r,��(' � I � O S <br />i, the property owner, request fo have the City of Everett Backwafer Preven#ion Qevice rebate check <br />for the installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to the vendar, I agree to the fol[owing: <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 not exempt me from Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release of my rebate to the vendor listed on the back of this form pending <br />approval of the compfeted Sackwater Prevention Device rebate packet by the City o# Everett <br />. <br />.. <br />_ _. <br />, _ -.---. <br />_� ._.. <br />�. <br />Signature af Property Owner <br />�-�- j ��l �" <br />Date <br />