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Backwater Prevention Device Rebate Program <br /> Vendor payment Option Form <br /> Project Number: (City fo Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> r-- <br /> Property OwnerName: _JQ / �="���� — <br /> Installation Address; L�D �� � �P��� <br /> Ciry: }��� / / Slate: _ ���T' Zip:_ �� � <br /> Mailing Address (il dillerenQ: <br /> City: _ Slale:_ Zip: <br /> Email: Phone: ( ) <br /> Tolal Cost to Install Device (from contracfor invoice): 5_�C( � <br /> I, the property owner,.request to have Ihe City of Everelt Backwater Prevention Device rebate check <br /> tor the installation of the device at the above referenced property address be made payable to, and <br /> senl to, lhe vendor specified on lhe back ot lhis form. By'requesling lhe rebale check be made <br /> payable to the vendor, 1 agree to ihe following: <br /> 1. I will not receive a rebale check directly fro;n Ihe City of Everelt. <br /> 2. Assigning paymenl of the rebate to.lhe vendor does nol exempt me (rom Backv�aler <br /> Prevenlion Device Rebate Program requirements. <br /> � � � <br /> I authonze the release of my rebate to the vendor listed on the back of lhis form pc�iding <br /> approval of ihe completed Backwalei Prevention Device rebate packet by the C�ty of Everett <br /> cGLQ��� � 2 /.I� <br /> �Sig ature of Property Owner Date <br />