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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: <br /> Installation Address:')( �] <br /> City:* e-\f State: <br /> Mailing Address (if different): <br /> City: State: zip: <br /> Email: ,tin UM r Phone: , �n � <br /> Total Cost to Install Device (from contractor invoice):$ ,� Y <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 to the vendor, I agree to the following: <br /> 1. 1 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 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 /> C_ <br /> Signature of Property Owner Date <br />