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Backwater Prevention Device Rebate Program <br /> ZErr Vendor Payment Option Form <br /> Project Number: (City/oProvide) <br /> Please complete both sides ofthe form <br /> Property Owner Section: <br /> Property Owner Name. 116 <br /> City: -e'(p�e -j–­ —State: Zip. <br /> Mailing Address(if different): <br /> City: Slate* Zip: <br /> Email: Phone: <br /> Total Cost to Install Device(from contractor 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 0Jthe vendor, |agree tothe following: <br /> 1. 1will not receive urebate check directly from the City nfEverett. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br />