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Backwater ire Devic&Rebate Frogs <br /> Vendor,Payment Option For <br /> Project Number: (City to Provide) <br /> Please complete both sides of the form <br /> Properit neck ion: <br /> Property Owner Name: <br /> Installation Address:_ rrt <br /> City: `s t <br /> 4 �l4 ''� ^.,�'a .tate: Zi :p <br /> Mailing Address(if dib`eront): <br /> City: State: gip: rs. <br /> Email_ la (\ "L-ACk • s iii Phone:(�CS�� �'atf;� � IZC <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 requesfing the rebate check be made <br /> payable to the vendor, l agree to the following: <br /> I I will not receive a rebate check directly fiorn 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 /> r <br /> I authorize the release of my rebate:to the vendor listed on the back of this form pending , l <br /> approval of-the completed BackwaterPrevention Device rebate_}packet by the City of Everett <br /> Signature of Property Owner Date <br />