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�ac�w�t�r IPrevea���or� Llev�ce Ref��t� P'�-�grarn <br />E� �/enda�' Payment �;p��on �ar� <br />Project Number: (City to Provide) <br />Piease �omplete bot� sides of �he form <br />prope�t� Owner �ecfiion: <br />Property Owner Name: _ F:���� C��� 1-�����`" <br />installation Address: � �-�' �� �'-�'�'�� <br />� ���_� State, i�1,� y� _ Zip: ����1 <br />City: � - t� �.-t� �=1�. . <br />Mailing Ad�iress (if drff�reni}: - `�c'� <br />Clty: t state: ��- Zip.��—, "" 3 7 -- <br />� ' -•. � <br />Email: <br />��` �y Phone: �'d.�l ��i `Y ��C�� <br />iotai Cdstto install Device (from contractorinvoice): $, �.�`�� �' �1 � <br />I, #he property ow��r, request to have the City of Everet# Sackwater Prev�niion Device rebate check <br />for the instaliatior� of the de�ice at the above referenced property address be made payable to, and <br />s�nt #o, the vendarspeci�ied an the back of this form. By requesting the rebaie check ba made <br />payable to the veridar, ! agree to the foElawing: <br />1. 1 wiEf not raceive a rebate check direatiy #rom the Gity of Everett. <br />2, Assigniric� payment o� the rebate to the vendor does not exempt me from Backwater <br />Prevention,Device Rebate Program requir�ments. <br />I authorize the relsase �f my rsbate to the vendor listed on the back of this fori� pending <br />approval af the �ornpleted Backwater Preve�tion Device rebate packat by the City af �v�ret� <br />� <br />._`.� � " - <br />Signature of Property Qwr�er <br />� <br />. 'Z,�z�- <br />l <br />Date <br />