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i <br /> Backwater Prevention Device I <br /> � Rebate Program <br /> For internal Use: Nroject Numbec <br /> Vendor Payment Option Form <br /> I <br /> iPlease complete both sides of the form <br /> Property Owner Section (please print): <br /> ; — - — f <br /> � �J�2 ��i�S ! <br /> I <br /> Property Owner Name � <br /> ' � ��� 7 c�k�, /J„� E���-�t �„�'f� 1,��z v� � <br /> Property Address City State Zip � <br /> 7y�v ���� �4.Y.�;�•�•/% �A �'k z7 a C <br /> Aiternate Ma lin Address � <br /> I 9 City State Zip <br /> ' �azs �� - //us �/(• J/��� <br /> _ � � 5 � �' Ct��l/ eJ . GJw <br /> Phone Emeil <br /> I <br /> I, the�Property Owner, request to have the City of Everett Backwater Pravention Device , <br /> rebate check for the installation referenced at the Property Address be made payable ! <br /> to, and sent to, the Vendor. By requesting the incentive/rebaie check be made payable <br /> to the;Vendor, I agree to the following: , <br /> 1. I will not receive a Backwater Prevention Device re:bate check direclly from the ! <br /> City of Everett. � <br /> 2. Assigni�g payment of the Backwater Prevention De�vice rebate to the Vendor � <br /> does nof exempt me from Backwater Prevention De��ice Rebate Program ; <br /> : requirements. I <br /> I II aulhorize the release of my rebate to th� Vendor listed on page t�•�o of this form <br /> pendinr� approv�l of the completed Eackwater Prevention Device rebate package by <br /> lhe Cily of Everett <br /> i <br /> � <br /> � <br /> � ��"1_S�/S <br /> Signafuro fPropf�RyOwner Date <br /> I <br /> � <br /> � Paye 1 of Z <br /> Revised 9l�izn i� <br />