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/,_`/��' Backwater Prevention Device Rebate Program <br /> �iw��/+�T Vendor Payment Option Form <br /> �.�--- <br /> Project Number: (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: � U� ` ���"' � <br /> Installalion Address: Ia'�� `'/nY�E g / <br /> City: �'�� State. �� Zip: �o�"�I <br /> Mailing Address (i/diNerent): <br /> City. State. Zip _ <br /> Email: Phone. ( ) <br /> Total Cosl to Install Device (Irom confractor invoice): S� l �I '1 �� <br /> I, the property owner, rey�est to have the Cily of[verelt Backwater Prevention Device rebate check <br /> for the inslallalion of thc device at lhe ahove referenced property address be made payable lo, and <br /> sent to, Ihe vendor speci'ied on lhe back of lhis form. By requesling the rebate check be made <br /> payable to the vendor, I agree lo lhe foilowing. <br /> 1. I wid not receive a rehale check direclly irom lhe City of Everett <br /> 2 Assigning payment of lhe rebale to the vendor does not exempt me from [3ackwaler <br /> Prev_ntlon Uevice Rebate Program requirements. <br /> I authonze the release of my rebatc to ihe vendor listed on lhe back of this form pending <br /> approval of the compleled Raclnvater Prevenlion Device rebale packel by the City of Everett <br /> �t� UU)� � f��r�n1e1' �"17�1� <br /> Signature of Property Owner Dale <br />