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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: � _ ' � � - �� <br /> Installation Address: I!� I� �D r�K�� '1/F — <br /> City: ��/�C2�'("T Stale:�t,/�Zip: � Q Z� ( <br /> Mailing Address(if difierent): <br /> City: State: Zip: <br /> Email: Phone: ( ) <br /> Total Cost to Instail Device (lrom contracfor invoice): $��� <br /> I, the property owner, request to have the Ciry of[verett Dackwater Prevention Device rebate check <br /> for the installalion of the device at the above referenced property address be made payable to, and <br /> sent to, the vendor specified on the back o(this form By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> t. I will nol receive a rebate check directly(rom the City ot Everelt. <br /> 2. Assigning paymenl of the rebate to tlie vendor dc�es not exempt me irom Backwater <br /> Prevention Device Rebale Program requiremenls. <br /> I authorize ihe relcase of my rebate lo tlie vendor listcd on Ihe back of lhis torm pending <br /> approval of the compleled Dackwaler Prevenlion D�vice rebale packet by lhe City o(Everett <br /> � C�/�cr — ' � — <br /> Signature oi Property O�vner Date <br />