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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (Cify to P�ovide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: �' ` (�CL(u �c.C.,E T L-'�� � <br /> Installation Address: ��Z� ��� �N" <br /> City: �1lr.�,E� State: I�1� _Zip: `'� ei 2��1 —l S U� I <br /> I <br /> Mailing Address(i(dil(erent): <br /> Ci�y: --- State: Zip. <br /> Email: Phone: ( ) <br /> Total Cost to Install Device (lrom �ontractorinvoice): $ <br /> I, the property owner, request to have�:ie Cily of Everett Backv�aler Prevention Device rebate check <br /> (or lhe installalion o(Ihe device at thi+above referenced property address be made payable'to, and <br /> sent to,the vendor specified on the ba^k of�r�s (orm. By requesting lhe rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I v�ill not receive a rebate check direcUy irom the City of Everett. <br /> 2. Assigning payment o(the rebate to Ihc vendor does not exempt me from Back�vater <br /> Prevention Device Rebate Program requiremenls. <br /> I authorize the release of my rebale lo the vendor listed on the back of this form pending <br /> approval o(ihe completed Backwater Prevention Device rebale packet by the City of Everett <br /> ���K,..-_ ��tt� ( �� 2��� <br /> Signature oi Properly Owner oate <br />