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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form � <br />Project Number. (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Namer •'�'�� <br />Installalion Address: �/, �_ S M�>"y�'� � �J — <br />Cily:�l% <br />Stale: �'`�� Zip: �o`�� <br />�"_ <br />Mailing Address (i(dilferentJ- <br />City: <br />State: <br />Email: _ Phone: ( ) <br />Total Cost lo Inslall Device (from contractor invoice): $_(7i�`"6_SL` a� <br />I, Ihe properly owner, request to have Pie Cily of Everett Backwater Prevention Device rebale check <br />tor the inslallation oi the device at the above referenced property address be made payable lo, and <br />sent to, the vendor specified on lhe back of this form. By requestirg the rebale check be made <br />payable to Ihe vendor, I agree lo the tollowing� <br />1. I will not receive a rebate check dire.r.Uy (rom the City o( [verell. <br />2. Assigning payment of Ihe rebale lo Ihe vendor dor.s not exempl me from L3ackwater <br />Prevenlion Devir.e Rehate Prograrn requirements. <br />I aulhorize Ihe releasc of my rebate to the vendor listed on Ihe back of this form pending <br />approval of the compieted Backwater Prevention Device rebat� packet by lhe Cily of Everetl <br />� `� <br />�, . _—,—�—_---- — <br />Signature of Property Ovdner <br />��/��� <br />Date <br />