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� :, <br />�'� <br />�� <br />Backwater Prevention Device <br />Reba#e Program <br />For internal Use: t'roject Number: <br />Vendar Payment Option Form <br />Please complete both sides of the form <br />Proper#y Owner Section (please pr�nt}: <br />Qr�-T12-i G� EM Ct� l R� G, �--N , i� �-�-t3/��f- , WI G1C11 /t �,a-►-� <br />Property Owner Name <br />17324 �'h c 2,��s nr� l�� i�-�L�v�o-a � c.�- - �'i � 9�� <br />Property Address City S#ate Zip <br />Alternate Mailing Address City State Zip <br />3��- ���-7�9 ,�d���,���s,;� ; c�„�- <br />Phone Ernail <br />(, the Properiy Owner, request ta have the City of Everetk Backwater Prevention Device <br />rebate check for the installation referenced at the Property Address be made payable <br />to, and sent to, the Vendor. By requesting the incentive/rebate check be made payabie <br />to the Vendor, I agree to the following: <br />1. I will not receive a Backwa#er Prevention Device rebate check directiy from the <br />City of Everett. <br />2. Assigning payment of the Backwater Prevantion Device rebafie to the Vendor <br />does not exempt me frorn Backwater Prevention Device Reba#e Program <br />requirem�nts. <br />I authorize the release of my rebate to fihe Vendor listed on page two of #his form <br />pending approval of the completed Backwater Prevention Device rebate package by <br />the City of Everetk <br />�-- --- <br />� �..�--��Z�.� <br />Signafure of Properiy Owner <br />�-�'-2��� <br />Dafe <br />Page 1 of 2 <br />Revised 9/3(2014 <br />