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Backwater Preverition Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. (Ciry to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />., , . <br />Property Owner Name: ; �� / � <br />Installation Address: _�, /�� /lU�-/��'/ r iiCi �— �' " `� ' <br />City: �1��2.C: %% state: G✓/�- • Zip: ' ���, �� <br />Mailing Flddress (if diKerent): <br />City: Slate: ��p: <br />Email: C� ;: /'S/%'��02F (µ'/r7S/U. �o m Phone: ( ) <br />Tolal Cost lo Install Device ((rom contractor invoice): S �3l •�`� <br />1, tho property ormer, request to have the City of Everett Backwater Prevention Device rebate check <br />for the inslallation ot the device at the above_referenced property address be rriade payable to, and <br />sent to, the vendor specified on the back of this form. Eiy requesting the rebale check bc made <br />payable to lhe vendor, I ac�ree to the following: <br />I will not receive a rebate check directly from the City of Everett. <br />Assigning payment of the rebate to the vendor does not exempt meYrom Back�vater <br />Prevenlion �evice Rebale Program requirements. <br />I authorize the rclease of my rebate to Ihe vendor listed on the back of this Form pending <br />approval of lhe completed Backwater Prevention Device rebate packel by the Ciry of Everett <br />���� ^ �yq�/�� <br />U(�JI� /�f�L�L� 4� <br />.- i <br />Signaturo of Property Owner <br />i' lZ-Zi'-l.5 <br />Date <br />