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�ck�nrat�r Prevention D�vice Re�a�e Prca��ram <br />Vendor �ay�nent �p���►n �arm <br />Project Number: (City to Provide) <br />Please compleie bath sides of the form <br />PropeMy awner Section: <br />Property Owner Name: <br />� <br />r <br />Installation Address: ,��"�.� � t3 Yt�i ��7��,�-k'� <br />Ci#y: � ��'���` � State: uV �"" Zip: �(�. <br />Mailir�g Address {if differenf): <br />Cify: <br />Email: <br />State: <br />zip: <br />Phone:( ) <br />Tota1 Cost to Instaif Device (from contractortnvoice): $��.,��� r�-`� ��_ !�l/� <br />t, the property 4wner, request to have the City of Everett Sackwater Prevention [?evice rebate check <br />for the installation of the device at the above referenced property addr�ss be rrt�de payable to, and <br />sent to, the vendor spec9fied on the back of ihis form. By requesting the rebate check be mad� <br />�ayabl� ta the vendar, t agree to the fol(owing: <br />'[. f will no# r�ceive a rebate check directiy from the City of Everett. <br />2. As�igning payment of the rebate to fhe vendor does nat exempt me from Backw�ter <br />Prevention Deaice Rebate Program requirements. <br />f authc�rize the reiease af my rebate tn the vendor listed on the back af fhis form pending <br />approual of the completed Backwater P�evention Device rebate pack�t by fh� City of �verett <br />gnature of Praperty <br />. �; � C�. 2c <br />Date <br />� <br />