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Backwater Prevention Device Rebate Program <br /> Vendor ynn prion Fore <br /> Project Ali tuber._ tri Pre p vide) <br /> Please rmpto both sides of the forret <br /> Property Owner Section: <br /> Property Owner Name: V)t �-t c° <br /> { _ <br /> Installation Address: _ t ,tw <br /> City. fi--i F . " " .._ _ State., h1A Zip: r I <br /> ` t <br /> Mailing Address(if Arent). <br /> City: _ State' _Zip_ L <br /> Email' f €t "r a "` 4k' 'hCane;( .) t' <br /> Total Cost to Install Crevice(from contractor invoice):$ <br /> t,the prop"owner,request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at this above referenced properly:address be made payable to,and € <br /> sent to,the vendor specified on the back of this fond.By requesting the rebate check be.made <br /> payable to the vendor,I agree to the following: <br /> 1. l will not receive a rebate check directly from the City of Evereff. <br /> 2. Assigning paymentof the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my rebate to the vendor fisted 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 <br /> Date <br /> t <br /> E <br /> _ - t <br />