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Backwater Prevention Device <br />Rebate Program <br />For internal Use: Project Number: <br />Vendor Payment Option Form <br />Please complete b�th sides of the form <br />Property Owner Section (please print): <br />Property Owner Name <br />Property Add <br />' Alternate Mailing Address <br />� <br />Phone <br />a�� 3�y <br />(� ' City <br />t-r��!7 `� �lj <br />Cily <br />n Email: <br />� d— <br />State <br />� <br />Zip <br />1, the Property Owner, request to have lhe City of Everett Backwaler Prevention Decice <br />rebate check for the installation ra(erenced at the Proaerty Address be made payable to, <br />and sent to, the Vendor. By requesting lhe incentive�rebate clieck be made payable to the <br />Vendor, I agree to the follov�ing: <br />1. I�vill not receive a Backaater Prevention Device rebate check directly from the <br />City o` Everett. <br />2. Assigning paymenl oF lhe Backwater Prevention Device rebate to the Vendor <br />does not exempt me irom 8ackwater Prevention Device Rebate Program <br />requirements. <br />I authorize the release of my rebale to the Vendor listed on page hvo of this form pending <br />approval oi the completed Backwater Prevenlion Device rebate package by the City of <br />, Everett i� /��� ���/�J! <br />`—I i�1� <br />Siqnature of Property Owner <br />Date <br />Page 1 of 2 <br />Revised 9/31201< <br />� <br />