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�� <br />F3ackwater Prevention Device Rebate Program <br />tv c.Ve�dor Payment Option Form ._ <br />Project Number: __ ___ (Ciry to Prowde) <br />Please complete both sides of the form <br />Property Owner Section: <br />- -- �r= <br />( Property Owner IJame: .l1 <br />,� <br />Inslallati�ddre,s���(� �L!Yi �� \ l � <br />��-�— <br />City� J�� State: _�� zip:� FJ�O�_. <br />i <br />tvtailing Address (il ddleren�) ��S ,30 y��p ��'_�R_ � G <br />� <br />City: �/,C�.�� _ . Stale: � Zip: � �Q � <br />/I y� y� �' <br />EmaiCl�O„�_� � _!14�N ' G��_Phone ( 1 -------- <br />Total Cost to Install Gevice (irom coMractor invoicej: $��v �� <br />i, the property o�vner, request to have the Ciry of EvereP, Baclavater Prevention Device iebate ched- <br />for the installation of ihe device at ihe above referenced property address be made paya6le to, and <br />sent to, the vendor specilied on Ihe bacic ol ihis form. Oy reque;t�ng Ihe rebate check be made <br />payable �o lhe vendor, I agree to the follov�ing: <br />1. I will nol receive a rebate check directly Irom ihe City of Everett. <br />2 �ssigning oaymenl of the rebate to ihe vendor does not exempt me (rom L'ack:vatar <br />Prevention Devicc Re6ate Program requirements. <br />�------ ---------- __ _ — --- <br />I authorize the release of my rebate to the vendor listed on ihr bacic of ttus Inrm pendmg <br />„F,proval of thc completed Backwater Prevenlion Device rebate packel by thc City o( Everetl <br />W'✓.f.L <br />Signature of �� rty Owncr <br />�- � <br />1� �--/� I <br />--- � <br />DaIP � <br />