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Backwater Prevention Device Rebate Program <br /> �. Vendor Payment Option Form <br /> Prajecl Number: (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> , /��., <br /> Property Owner Name: �� • C� 1�-- �/T� ii7 <br /> Installation Address' ��jl'7 A��./<�-cn�r- ��,(.�' <br /> City: � � %P State' �1� Zip: �S./�� <br /> Mailing Address(i(dilterent): a'��d� O' '� L�✓�i I Y <br /> City: _,_/����1�.�� State: 1� _Zip: `( ���r <br /> EmaiL_�� C�/%�'I(1[����,}�- Phone: C�2]}�(,���J34, <br /> Total Cost to Install Device (from contractor invoi;e): $ O'y� L� • 3 � <br /> I, the property owner, request lo have the City of Everett Backtivater Prevention Device rebale check <br /> for the installation ot the device at the above referenced property address be made payable to, and <br /> sent lo, the vendor speci(ied on the back of this (orm. By requesting lhe rebate check be made <br /> payable to the vendor, hagree to the (ollowing: <br /> 1. I will not receive a rebate check directly from lhe Cily of Everett. <br /> 2. Assigning paymenl ol the rebate lo the vendor does nol exempt me Irom Backwater <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my rebate to the vendor listed on the back ot lhis form pending <br /> approval o(the completed Dack�vater Prevention Device rebate packet by the City of Everetl <br /> i� , ' <br /> y- Z v--� � <br /> Signature o(Property Owner Dale <br />