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; <br /> Backwater Prevention Device <br /> Rebate Program <br /> For internal Use: Project Number: <br /> Vendor Payment Option Form <br /> Please complete both sides of the form <br /> Property Owner Section (please print): <br /> F_I �2��.�`�-� ���s eN Kc�� <br /> Property Owner Name t��I /��) � / � <br /> (_ yt <br /> Property Address �\�it�2�State' A r� Zip���� / <br /> v� <br /> Altemate Mailing Address City State Zip <br /> Phone Email <br /> I, the Property Owner, request to have the City uf Everett Backwater Prevention Device <br /> rebate check for the installation referenced at the Property Address be made payable <br /> to, and senl to, the Vendor. By requesting the incertive/rebate check be made payable <br /> to the Vendor, I agree to the following: <br /> 1. I will not receive a 63ckwater Prevention Device rebate check directly from the <br /> City of Everett. <br /> 2. Assigning payment c'the Backwater Prevention Device rebate to the Vendor <br /> does not exempt me ri:?m Backwater Prevention Device Rebate Program <br /> requirements. � <br /> I authorize Ihe release of my rebate to the Vendor lisled on page two of this form <br /> pending approval of the co pleted Backwater Prevention Device rebate package by <br /> the City verett <br /> ;' <br /> � <br /> - � _ a j -,�v�� <br /> ignature of Property Owner Date <br /> Page 1 of 2 <br /> Revised 9/3/2014 <br />