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Backwater Prevention Device Rebate Program <br /> Tr Vendor Payment Option Form <br /> Project Number. _. ____.. (Ciry to Provrde) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ���_.�/. ��! C / <br /> Installation Address: � �� �� � <br /> City:�G1�� State:��.Zip: /�2�/f <br /> Mailing Address(il di/ferent): <br /> City: State: Zip:_ <br /> Email: Phone:�! ���� � <br /> Tolal Cost to Inslall Device ((rom contracforinvoice): $__?�O -� <br /> I, the property owner, request lo have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at ihe above referenced property address be made payable to, and <br /> sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to lhe following: <br /> 1. I will not receive a rebate check directly irom Ihe City of Everett. <br /> 2. Assigning payment of the rebate lo Ihe vendor does not exempt me (rom Backwater <br /> Prevention Device Rebate Program requiremenls. <br /> I aulhoriic the release of my rebate to the vendor listed on thc back of this form pending <br /> approval of lhe wmpleted Backwater Prevention Device reoate packet by the Gity oi Everett <br /> �y%.�'�i��-�—a--- �✓ %G�"/(� <br /> Signature of Property Owner Oate <br />