Laserfiche WebLink
Backwater Prevention Device Rebate Program <br /> EvZ7T Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> i <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ��,\ <br /> r� C, <br /> Installation' Address: <br /> City: State: ,i Zip: 1U <br /> Mailing Address (if different): S1ME <br /> City: State: Zip: <br /> Email: &I M LTt0 ] ) e MSPCLM Phone: (Z� 72-0 ' U-- <br /> Total Cost to Install Device (from contractor invoice): $ .- tJ <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 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 /> Date <br /> Signature of Property Owner <br /> I <br />