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� <br />Backwater Prevention Device <br />Rebate Program <br />Poi intcrnal Usc: I'iu;i•r.l i�!unilii�i. <br />Vendor Payment Option Form <br />Please completc both sides of the fonn <br />Property Owner Section (please print): <br />C��.'��s r-��o� <br />_.. <br />Property Owne Name <br />��%���k'`�- 1'}�1� GV�12�.T- �''.(j <br />Property Address Ciiy S�ai�� <br />Allemale 1�7ailing Address <br />Phone <br />9sw� <br />!ip <br />Ci�y _ _ Slalie !ip <br />Lm;iil ------ <br />I, the Property Owrer, rcquest �o have lhu City of tvcrel( Qackw�ili:� f'revention Ucvir.c <br />rebate check for the installation referesnced al Ihe Property Addre;;�; be in;�d�� �riynl�ln <br />to, and se�t lo, thr� Vendor. Gy iequcsting (he incenlive/rebale chcci b�: mncle p,�yablc <br />to Ihe Vendor, .' agree to thc (ollnwiny. <br />1. I will not receive a f3ackwala I'revc:nlion Devicc rebalr. e:heck riiiecUy frum Iha: <br />City of Fverelt. <br />2. Assigning payment of the I;ackwnlr_i Prc:venlion Device i��ba(e li� Ihe Vendor <br />does not exempf mc (roni (3ai.kwafer Prevention Device Rebalc Proi�r,ini <br />reyuirements. <br />I aulhorize tiic release o( my rebale to lhe Vendor lisled cn p�gc Iv;n �>I Ihi:: fnrm <br />pc:nding approval nf th� complel�d 13;3ckavatei Pr�vention Uevice iulrife �rir.kage I�y <br />the City of Fverett <br />1 <br />�I <br />------� — L-- -- — <br />Sign.dure olPiapr.i(y Owne;r <br />af////�j. _ <br />U�ilr, <br />I'.u�,• 1 ni 1 <br />I;� ror.r;l'P.�':'.11I�1 <br />