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Backwater Prevention Device Rebate Program <br /> Vendor PaymentOption Form <br /> Project Number, (City&uProvide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: <br /> Installation Address. L <br /> -57 <br /> Emaw -- <br /> Total Cost to Install Device (from confractor invoice):$ <br /> 1,the property owner,request to have the City of Everett Backwater Prevention Device 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 tothe vendor, (agree hothe following: <br /> 1. |will not receive mrebate check directly from the City cfEvereft. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br />