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i <br /> l <br /> Backwater Prevention Device Rebate Program <br /> 3 <br /> Vendor Payment Option Form <br /> f <br /> Project Number: (City to Provide) <br /> i <br /> Please complete both sides of the form <br /> Property owner Section: <br /> l <br /> Property Owner Name:Li`"`- ez <br /> Installation Address: 3. <br /> -��4 /City: ��� State: Zip= <br /> Mailing Address(if different): <br /> i <br /> City: State: Zip: 5 <br /> 5 <br /> Email ------ Phone: <br /> Total Cast to Install Device (from contractor invoice): $ t � <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 l <br /> sent to,the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, l agree to the following: <br /> i <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 5 <br /> Prevention.Device Rebate.Program requirements. <br /> i <br /> i <br /> 1 authorize the release of my rebate to the vendor listed on the back of this form pending <br /> ,:a4of <br /> Backwater Prevention Device rebate packet by the City of Everett <br /> wner Date <br />