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i � <br /> ' Backwater Prevention Device <br /> Rebate Program <br /> , For internal Use: Project Number. <br /> Ve;ndor Payment dption Form <br /> Please complete both sides of the form <br /> Property Owner Section (please print): <br /> �o�---�2 �,�.1r�+ <br /> Property;Owner Name <br /> r s,l—��...t..�� ��.� �,�/1 �JAlo/ <br /> Property Address Cily State <br /> _y17/- /�i'Ari• Zip <br /> s r Ncq/ ��n�� t� In/l�- 9/�L'IT <br /> Altemato Mailing Address City State <br /> 7_ip <br /> _�L5�5`I-f�/07 rt i����� L�J �r ui c� t1G� <br /> Phone [mail <br /> _ ! <br /> I <br /> I, lhe Property Owner, request to have lhe Cily of 6verett [3ackwater Prevention Device <br /> rebate check (or tho installation referenced at the Properly Address be made payable <br /> to, and sent';to, the Vendor. Dy requesting the incentivehe6ate r.heck be made payable <br /> to the Vendor, I agree to the following: <br /> 1. I will not receive a Backwater Prevention Device rebate check directly from the <br /> City of Everett. <br /> 2. Assigning payment of the (3ackwater ('revenlion Device rebate to the Vendor I <br /> does,no! exempt me from Ciackwafer Prevention Device Rebate Program <br /> requi�ements. <br /> I authorize;the release of my rebatc lo lhe Vendor listed on page lwo of this form <br /> PE-���1ii�� �npruval oF the completed Backwaler Prevention Device rebate packagc by <br /> the City of Everelt <br /> .��� �I/��, � <br /> / Yu�.�-- 7-7> -/S � <br /> Slqnafure of PmpoNy Ownor Date <br /> Rr.visedi�l�l�p1,4 Pa�c 1 of 2 <br /> I _ <br />