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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 fihe form <br />Property Owner Section: <br />Property Owner Name: �t215 t�,� (`�jC'�'S�� j�.,� <br />Installation Address: �32 .1 '���. -{�� <br />CitY� ��_.—�� State: � �, , — Zip: �� `� �""'i ` <br />Maiiing Address (if different): �,���,. �� .����� <br />City: State: Zip: <br />Emai�: T�iS�P�C�y ��° y���(� . CbtN� Phone: (� G� 1- Z�?�.-C� <br />Total Cost to Instali Device (From contracfor invoice): $ '�- , w, C�C.�� �� <br />I, the property owner, request to ha�e the City of Everett Backwater Prevention Device rebate check <br />for the insta�lation of the device a# the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back af this form. By requesting the rebate check be made <br />payable to the vendar, I agree to the following: <br />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 fhe back nf this form pending <br />approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br />,�'"..�'` <br />�-'`� �.�---�. �.,�.�-,-----."_ _ �� .., t� � i� <br />� <br />Signature of Property Owner Date <br />