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Backwater Prevention Device <br /> � Rebate Program <br /> For internal Use: Project Number: <br /> Vendor �aayment Option Form <br /> Please comple?e both sides of the form <br /> Property Owner Section (please print): <br /> i Property Owner Name'�`�n(� �; �1,1 c�`�-. <br /> J �__ 4 <br /> � Property Address Ci State n��� I <br /> I, 3�-1 ol� I c��m l�'-�a,�rc� �����--� i,v�k `�' <br /> � Alternate Mailing Ad ress City State Zip <br /> � J j J" �ni F�p��-.�t�Q'�-'� ��..2' �U��—f.�L--✓1—��� � <br /> Phone Email: � S � � A,�� �'y-� <br /> ��5- �a3� - � a� � Y � � --- <br /> 1, the Property O�vner, request to have the City of Everett Backwater Prevention Device <br /> rebate check for the installation referenced at the Property Address be made payable io, <br /> and sent to, the Vendor. By requesting the incentivelrebate check be made payable to the <br /> 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 Backwater Prevention Device rebate to the Vendor <br /> does not exempt me from Backwater Prevention Devlce Rebate Program <br /> requirements. <br /> I authorize the ielease of my rebate to lhe Vendor listed on page two of this form pending <br /> approval of the completed Backwater Prevention Device rebate package by the City of <br /> [veret <br /> �� - � 3S_J�- <br /> 3 s � 9 i��ck.�.-rrc�.�. y�-Z-� i <br /> Signature of Properfy Owner , Da te <br /> Page 1 of 2 <br /> Revised 9/3/2014 <br />