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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projec'. Numbec (City to P�vide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vner Name <br />Installal on Address: __�% �� a� �� �'�� S / J V�� � <br />Cily: �_� e��_ S'ate: (�J�t ZiF: ��.�( D/ <br />Mailing Address (i/ different): � S <br />, City: State: _ Zi <br />, �S �e <br />Email Phone: (H�S) �2 5 tI 'ti37�9 <br />Total Cost Io Install Device ((rom cor�trac�or invoice): $����.L _ <br />I, the property ovmcr, requesl to have tne City of Everett Back�vater Prevention Device rebate check <br />for lhe mstallation of the device at the al�ove referenced property address be made payable lo, and <br />sent to, the vendor specified on the back of this (orm. By requesting the reba�e check be made <br />payable to lhe vendor, I agree to Rie (ollowing: <br />1. I�vill not receive a rebate check direclly from Ihe City of Everelf <br />2. Assigning payment of the rebate lo Ihe vendor does not exempt me from Nackwate� <br />Prevention Device Rebate Program requirements. <br />� f aulhonze }he release of my rebate to lhe vendor lisled on the back cf Uiis form pending <br />approval o( the completed Backv�ater PrevenUon Device reUale pachel by the Cify of Fverelt <br />; T`` �� JCf• X�/cE�r- -w i� =�"-y— /�j' <br />Signature of Property Owner Date <br />L— - --- — -- <br />