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Backwater Prevention Device Rebate Program <br />Vendor Payment Opiion Form <br />Praject Number: (City fo Provide) <br />Please complete both sides of the form <br />Property Owner Secfion: <br />Prope�ty Owner Name_ S <br />�1¢,� �G�� <br />1 A -_ <br />Instaliation Address: 3��� T�f�4 /� <br />City: �� State: �/►�/4 Zip:_ l0 �{ <br />Mailing Address (r`f different): <br />City: <br />Email: <br />State: <br />Zip: <br />Phone: { ) <br />Toial Cost to Install Device (from contractor invoice): $�,� �� c� <br />1, the property owr�er, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation of the device ai the above referenced properfy 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 foflowing: <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 />Preventian Device Rebate Program requirements. <br />1 authorize ihe release of my rebate to the vendor listed an the back of this form pending <br />approval of the compfeted Backwater Prevention Device rebate packet by the City of Everett <br />� <br />Signature of Property Owner <br />Date <br />