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t <br /> t <br /> i <br /> Backwater Prevention Device Rebate Program <br /> I <br /> Ev Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> { <br /> Please complete both sides of the form <br /> T <br /> X <br /> Property Owner Section: F <br /> Property Owner Name: <br /> a <br /> s <br /> Installation Address: c-ri L'4 V'� j <br /> City:blagt-� State: L')* Zip: CtIk-20 <br /> Mailing Address (if different): <br /> City: State: Zip: <br /> Email: Phone: ( ) <br /> p <br /> Total Cost to Install Device (from contractor invoice): <br /> s <br /> I,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 to the vendor, I agree to the following: <br /> 1. I will not receive a rebate check directly from the City of Everett. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> i <br /> I authorize the release of my rebate to the vendor listed on the back of this form pending <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> t <br /> Signature of Property Owner Date <br /> s <br /> s <br /> i <br /> t <br /> i <br /> i <br /> Fyy <br /> '8 <br /> i <br />