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� <br /> � <br /> iBackwater Prevention Devica <br /> Rebate Program � <br /> I <br /> For internal Use: Project Numbcr: ____ _ ; <br /> � � <br /> Vendor Payment Option Form �4 <br /> ! <br /> Pleasc complete both sides of the form i <br /> Propeity Owner Section (please print): <br /> ��, x;,�� <br /> - f <br /> ; Property Owner Name <br /> i�or. l'4tw, SE. E"„����rt wA pSz�; ! <br /> - --- -- ! <br /> Property Address City State Zip � <br /> Altemate Mailing Address Ciry State/� Zip i <br /> �ZS SC/ ��g0 /.�furJ$�.5L6t7 dulfiva�l.flr�il I <br /> Phone Emait � <br /> i <br /> I, the Property Owner, requesl to have the City of Evered BacVavater Prevention Devi�e ' <br /> rebate check for the installation referenr.ed at the Property Address be made payable � <br /> to, and sent to, the Vendor. By requesting the incentivelreba'e check be made payable � <br /> to the Vendor, I agree lo the following: � <br /> 1. I will not receive a Backwater Prevention Device rebate check directty irom the ; <br /> City of Everett. ; <br /> 2. Assigning payment of the Backwater Prevention Device rebate to the Vendor i <br /> does not exempt me from Backwater Prevention Device Rehate Program � <br /> requirements. � <br /> i <br /> I authorize the release of my rebate to thP Vendor listed on page two of this form I <br /> pending appraval of the completed �ackwater Prevenlion Device rebate package by , <br /> the City oi Everett : <br /> C�, 1 I <br /> 4,�� ��lu(' --- - - �?�/�/��� i <br /> � { <br /> Signafure o(Prt�perly Owner Date <br /> I <br /> I <br /> i <br /> F'age 1 of 2 � <br /> Revised 9/372014 i <br /> i <br />\ <br />