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� <br /> I <br /> ; <br /> Backwater Prevention Device Rebate Program ! <br /> Vendor Payment Option Form ' <br /> � <br /> , <br /> Project Number:__ (Ciry to PrtrvideJ 1 <br /> ; <br /> � <br /> Please complete both sides of the form � <br /> i <br /> Property Owner Section: � <br /> (�/ � � <br /> Property Owner Name: � �/� ,("n/�Qh � �Gi� J?Lar.�eU4nf � <br /> / / I <br /> Inslallation Addressc �� n� (�(��o .f �}fl t � <br /> �Ls� ' <br /> City: � '2te� State: �n1�.1 Zip: � �4 I I <br /> I <br /> Mailing Address(if diffeienQ:_. _ <br /> City: State: Zip: � <br /> Email:� f n �/ G�i��Gi � �vM Phone: (y;���S! /SJ� <br /> Total Cost to Install Device (Irom conUacforrnvoiceJ: $ � 1�����1 � <br /> i.S-fin�G�'' ' <br /> _ i <br /> 1, ihe property owner, requesl to have the City of Everett Backwater Preventlon Device rehate check <br /> for the installation of the device at the above referenced property address be made payable lo, and ! <br /> sent to,the vendor specified on the back oi this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: � <br /> 1. I will not receive a rebate check direcUy from ihe Ciry of EveretL � <br /> 2. Assigning payment o(the rebate to the vendor does not exempl me from 8ackwaler <br /> Prevention Device Rebale Program requirements. ; <br /> i <br /> — I <br /> I aulhorize the release of my rebate to the vendor listed on the back of this form pending I <br /> approvaf of the completed Backwater Prevention Device rebale packel by the City of Everett I <br /> � <br /> i <br /> � , � , �1� i <br /> Signal e of ropeity Owner ate i <br /> � <br /> � <br /> I <br /> i <br /> � <br /> I <br /> ; <br />