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, <br /> Backwater Prevention Device <br /> Rebate Program <br /> For tntemel Use: Project Number: <br /> Vendor Payment Option Form <br /> Please complete both aides of the form <br /> Property Owner Section (please print): <br /> _�.�1Z�ct�A <br /> Property 0 / /�,Z. I P/1/Y�l�,��. �Q q tl �D� <br /> Propertyg�ress City � Stale ip <br /> t59��Zlll� �� �v� cva • 9�" `� <br /> Altemate Mailin Address City State Zi <br /> 4x -s`��T3v� �1��/�C�RP��,��,�SN cnn� <br /> Phone Email <br /> I, the Property Owner, request to have the City of Everett Backwater Prevention Device <br /> rebate check for ihe Installatlon referenced at the Property Address be made payable <br /> to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br /> to the Vendor, I agree to the following: <br /> 1. I will not rece(ve a Backwater Prevenlion Device rebate check directly from the <br /> City of Everett. <br /> 2. Assign(ng payment of lhe Backwater Prevention Device rebate to the Ver..lor <br /> doAs not exempt me frorn Backwater Prevention Device Rebate Program <br /> requirements. <br /> I authorize tha release of my rebate to the Vendor Ifsted on page iwo of this form <br /> pending approval oi the completed Backwater Prevention Device rebate packt�ge by <br /> the City of Everelt <br /> ��,�J�`��,C,� <br /> Signat re of Property wner Date <br /> Revised 9/3/2014 Pa6e 7 of 2 <br />