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� Backwater Prevention Device Rebate Program <br />Vendor,Payment Option Form <br />Projecl Number. (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />InstallationAddress� v�.3i� (/���wlA �U% <br />City: � U C��c 1� _ Stale' vy��___ Zip. ��d� �� <br />Mailing Address (il dilferent): <br />ciry: <br />State. <br />Cmai�: `�P�9t�TEL��@_�1�C'.IL� Pnone�(uay' ��� — ���a <br />Total Cost !o Inslall Device (6orn conNactor invoicef S_a y�� �� <br />I, lhe property owner, request to have lhe City o( Gverett Backwater Prevention Device rebate check <br />for the installalion of the device at the ahove referenced rroperly address be irmde payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check l�e made <br />payable lo the vendor, I agree to Ihe following: <br />1. I vaill not recerve a rebate r.heck directly irom the City of [verelt. <br />2 Assigning payinent oi Ihc rebale ro the vendor does nol exempt n�e from Backwater <br />Pievenlion �evice Rebalr. Program requiremenls. <br />I aufhorize lhe release of my rebate lo the vendor listed on the back of this torm pending <br />approval of lhe completed �ackwater Prevenlion Devir,e rehate packet hy Ihe Ciry o( Cverell <br />� f�( � _--- --- 3 — I i -�— <br />Signature of Property Owner Dafe <br />