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�Backwat�r Prevention Device Rebate Program <br />rr Vendor Payment Option Form <br />Pra;oct Numbec (City ro Provide) <br />Please complete both sides of the form <br />Property Owner 5ection; <br />Propeny Ovmcr <br />Installntion Address: LLX)� �'�,{ W�`E'_l�-- I,Yt��-� <br />Gty� � j`�Li�hT Stale: ___�_.�_ Zip: / x/i : � <br />Molling Address (il diHerenl}: _�/�V�C <br />City <br />Emall: <br />Stale <br />2ip: <br />Phnne ( <br />Total Cost lo Install Davico (from contrector inuoice) 5 L�S� ��. �/ <br />I, Ihe propeAy a.vnor, request tc have the City of Evaret; 8ackwntor PrevenNon Devtce rebate cieck <br />for :ho installation of the device at the above referenced proporty address be made payable to, and <br />sent to, the vendor specilied on the back of this lo�m. By raquasting ihe rebata check Le made <br />payTbie to tne verdor, I r�rae tc the follov,ing: <br />t I vnll not receive a rebate checK direcUy hcm Ihe Cily of Everett. <br />2. Assigning paymen! of U�e rebate to the venUor cues nol exempt me from Backweter <br />Prevention Devicc Rebnla Pro{�r<�m requirc..enls. <br />1 au�horize the relcaso of my rebote to the vcndor Iisted on Ihe back of lhis torm pending <br />approval ot the comploted Bockwoter Ptevonbon Devico raboto pockel by Ihu City of Everett <br />�./ �7 `-T� <br />ti E�iLtu�.. - / � /�•�,�.� , i <br />,, <br />Signature ot Properly O�mer <br />�.. ' <br />_.: _-__�� _.—_....._..._..-__-----•- <br />-i .,. / ,� <br />