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� <br /> ��ck����r Pre�en�i�n ��vice Reba�e Prog��m <br /> Ver�c�ar IPayme�t Option Forr� <br /> Projec# Number: (City to Provide) <br /> � <br /> Please complet� bc��h sides c�f the f�rm <br /> Propert.y C�wner Sect'ton: <br /> a� / y ��, r <br /> Properiy Owner Name: �'���//��-`-� ��%� /��. /j�'' ��'i��'�,�, <br /> r <br /> (nstaflafiionAddress: ��`�.��� ,� ��__YY1 E��r�t,�-k'� <br /> Ci#y: "C.:����"7���` State: vV �" Zip: �� <br /> Mailing Address(if different}: ' <br /> City; Sfate: zip: <br /> Em�il: Phone: ( ) <br /> � <br /> �' � <br /> Totai Cost ta 1 nstalf �euic�(from contractar invoiee): $�p.,��� � �-�`'J �� /��.�` � ' <br /> i, <br /> . ; <br /> l,the property owner, request to have the City of�verett Backwater PreventEon flevice rebate checic <br /> for the€nstaqation of the device at the above referenceci property addr�ss be r�ade payable to, and � <br /> sent to, the vendar specs�ed on #he back of fhis forrn. By requesting the rebate check be made ' <br /> payabl�to the vendar, t agree to tt�e folfowing: � <br /> '1, I will not receive a reba#e check direct[y from the City of Everett. �', <br /> � , <br /> 2. Assigning paymen#of#he rebate to the vendor ddes not exempt me from Backwater ; <br /> Prevention Deuice Rebate Program requirements. ; <br /> — ----------- (' <br /> I authorize the release of my rebate tn the verrdot tisted on the back of this form pending <br /> approval of the compl�t�d Backwater Prevention�evice rebate pacicet by the CIty of Everett i <br /> � <br /> �'; <br /> `� � � ' . 2� � � <br /> � � � � ��. � <br /> r � � . <br /> ignature of Froperty Owner Date <br />