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Backwater Preventio�� Device Rebate Program <br />Vendor Payment Uption Form <br />Project Number: <br />(City fa Provide) <br />Please complete both sides of the form <br />Properry Owner Section: <br />Property Owner Name: J(� 1�� �� }2�� <br />Installation Address ��� �U lJ".�-�T }li��� �Y�.l_ U�SLX�-� 1� <br />��ri: -��,�2 r �,�.�- 5��: l,�`i�- Z�p: �' �iJZo 3 <br />Mailing Address (ildiffarenf): <br />Cily: <br />State: <br />Email: Phone: ( ) <br />Total Cost to Install Device (from confrdclorinvoice): $ �� 22 `� <br />I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br />for the installation oi the device at the above referenced property address be made payable to, and <br />sent to, the vendor specfied on the back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />t. I will not receive a rebate check direcHy from the City ot Everett. <br />2. Assigning paymenl of the rebate to the vendor does not ezempt me from Backwater <br />PreveMion Device Rebate Program requirements <br />I authorize the release of my rebate to the vendor listed on the back of lhis form pending <br />approval of the completed Backwater PrevenGon Device rebate packet by the City of Everett <br />\' ��'7�– – <br />Signature of Property Owner <br />�1– 1—�,� <br />Dale <br />