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Sackwater Prevenfion Dev�ce Reba�e Program <br />Vendor Payment Option Form <br />Project Number: (Cify ta Provlde) <br />Pfease complete both sides of the form <br />Property Owner Section: <br />Property Owner �iam <br />lnstallation Address: <br />City: �' 3� State: __�, �iP�_. � Oc.� i� f <br />Mailing Ad�ress (if drfferent}: <br />City: <br />Email: <br />State: <br />Zip: <br />P�one: �(`� '�? `��� <br />Total Cost to lnstall Device (frorrr cantracforrnvo)ce}: $ c�� �� �� <br />I, the property owner, request ta have the City of Everett Backwater �'revention Device reba#e check <br />for the installation of the device at the above referenced praperty address be rriade payabie to, and <br />sent to, the ve�dor specified on the back af this form. By requesting the rebate check be rnade <br />payable to the vendor, I agree to the fa)lowing: <br />l wifl not receive a rebate check direcfly from the City af Everett. <br />2 Assigning payment of the rebate to the vendor does not �xernpt me from Sackwater <br />Pre�ention Device Rebate Pragram requirements_ <br />I authorize the release af my rebate to the �encior listed on ti�e back of this forrn pending <br />approval oF the completed Backwater Prevention Device rebate pac[cet by the City of Evereti <br />� -�. <br />S' natu f Rroperky Owner <br />nY ' / / �., <br />P �� �� l �l <br />4�__ <br />Date <br />