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Backwater Prevention Device Rebate Program <br />� Vendor Payment Option Form <br />Project Number: <br />(City fo Provide) <br />Ptease complete both sides of the form <br />Property Owner Section: <br />Property Owner Name:� L�T�Sy,� C'rfT�-/nl <br />InstallationAddress:,�C ���'� ���� ��� <br />City: ���Y State: �✓/� <br />Mailing Address (if d�fferent): <br />City: <br />State: <br />Zi <br />Zip: <br />r�z�a � <br />Emai1: t�vrr.���Y�Z�Y�Hpd. LaM Phone: (�Z$) �7h�-6�3 z-- <br />Total Cost to Instalf Device (from contractorrnvoice): $ � 1. � <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 vendar listed an the back of this form pending <br />approval of the comp4eted Backwater Prevention Device rebate packet by the City ofi E�erett <br />Signature of Property Owner <br />� �- /y ,��, <br />Date <br />