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Backwater Prevent�on Device Rebate Program <br />Vendor Paymen# Option Form <br />Project Number: {Cify to Provide) <br />Piease complete both sides of the form <br />Property Owner Section: <br />Praperty Owner Name: ��� �- �,��`� i 1,�,�t'Z� <br />lnstallation Address: � �'�=�___``�S„��,�YL-�-� <br />City: � l,��f'JL_�' State: '��� _ Zip: �Rc��`.� � <br />Mailing Address (if different): <br />City: State: Zip: <br />Email: f'hone:� c� -�,-�G%(��Ci <br />s <br />Totai Cast to Install Device (from contracforinvoicej: $ p� �,�� <br />1, the property owner, request to have tha Cify of Everett Sackwater Preventian Device rebate check <br />for the instalia#ion 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 ta the vendor, I agree to the following: <br />1. I will not receive a rebate check direc#ly from the City of Everett. <br />2. Assigning payment of the rebate to the vendor does not exempt me �rom Backwater <br />Prevention Device Rebate Program requiremen#s. <br />1 authorize the release of my rebaie to the �endor listed on the back of this form pending <br />approval of the completed Backwater Preventian Device rebate packet by the City o# Everett <br />� <br />� . ���� <br />ignature of Property Owner Date <br />