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Backwater Prevention Device Rebate Progr:�m <br /> Vendor Payment Option Form <br /> Project uumber. _ (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> � � <br /> Property Oevner Name:�s'Y-t_ ��'C�� �.,1�[ 1 ( <br /> Inslallation Address: �� � �' �f�G�e�e 1 �� l`rt�� <br /> City� _�U e�(�V�-----Stale: �� Zip -1 U[�-�l <br /> Mailing Address (if dilferenf): !� __ <br /> City: State: _____Zip: __ � <br /> Email:� � � Ol ��CAY1�C),C c�1'1 Phone: ({?5) 'zl O � �0� <br /> Total Cost to Install Device ((rom con6ar.forinvoice): �__p�� '��_�j <br /> I, the properly owner, request lo have Ihe City ot Everett Backwater Prevention Device rebate check <br /> for the installalion ot lhe device at the above referenced property address be made payable to, and <br /> senl to, the vendor specified on the back of this (orm. By requesting the rebale check be made <br /> payable to the vendor, 1 agree to Ihe (ollo�vi�g� <br /> L I will not receive a rebate check direclly from the City of Everetl. <br /> 2. Assigning payment of the rebate lo !he vendor dnes not exempl me from Backwater <br /> Prevention Device Rebale Program reyuiremerds. <br /> I airthorize the relcase of my rebalc to Ihe vendor lisled on Ihe back of Ihis form pending <br /> �approval of the completed Backwater Prevention Device rebato packel by the City of Fverell <br /> -, <br /> � <br /> L " _- — _ lo I � '"I Z��S <br /> <�i`�/ " - � <br /> T <br /> Signature of Property er Dale <br /> - ---- ----- -- J <br />