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Backwater Prevention Device <br />Rebate Program <br />For internal Use: Project Number: <br />Vendor Payment Option Form <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />� <br />/��s� /,�,Ga��u�K <br />Property O�vner Na� e <br />,�'!02 �,�rCr-fr-//F,i ri✓E. F✓rs��t l,�,s i't!1c�/ <br />Property Address <br />Alternate Mailing Address <br />yJ-S-S/�S-`� ll <br />Phone <br />City <br />City <br />Email <br />State Zip <br />State Zi� <br />I, the Property O�vner, request to have the City of Everett Backwater Prevention Device <br />rebate check for the installation referenced at the Property Address be made payable <br />to, and sent to, the Vendor. By requesting the incentivelrebate check be made payable <br />to the Vendor, I agree to the following: <br />1. I will not receive a Back�vater Prevention Device rebate check directly from the <br />City of Everett. <br />2. Assigning payment of the Backwater Prevention Device rebate to the Vendor <br />does not exempt me from Backwater Prevention Device Rebate Program <br />requirements. <br />I authorize the release of my rebate to the Vendor listed on page iwo of this form <br />Fe�ding approval of the completed 6ackwater Prevention Device rebate package by <br />the City of Everett <br />/ <br />.-r`c � - <br />Signafurc of Properfy Owner <br />Rev�sed 9l3�2014 <br />�_,Z 9=/ 5` <br />Date <br />Pagc 1 of 2 <br />