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�w��� Backwater Prevention Device Rebate Program <br /> 'Jendor Payment Option Form <br /> Project Number: _ (City fo ProvideJ <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Properly Owner Name: �l�l��� �/�L1�(�'��C.� . /n C <br /> Instatlation Address: �z WKC�(� fi'�"+u�- <br /> City: ��'��'�� ,Slate: W�_. Zip: 7`i} �/ <br /> Mailing Address(i(diHerent): <br /> City: Slate: Zip: <br /> Email: Phone: ( ) <br /> Total.Cost to Install•Device ((rom confracforinvoice): S <br /> � - i <br /> I, the property owner, request lo have the Cily of Everelt Backwater Prevention Device rebate check <br /> tor the inslallalion of the device al�he above re(erenced property address be made payable to, and <br /> sent to,the vendor specified on the back of this form. By requesling lhe rebate.check be made <br /> payable to the vendor, I agree to�he following� <br /> 1. I will nol receive a rebate check dtrectly from lhe City of Everett. <br /> 2. Assigning payment of the rebate to the vendor does nol exempt me from Dackwater <br /> Prevention Device Rebate Program reyuiremenls. <br /> I aulhor.ze the release of my rebale to lhe vendor listed on the back o(this form pending <br /> approvai of Ihe cornpleled Dackvraler Prevention.Device rebate packet 6y ihe City of Everelt <br /> ������� ��Zo /5� <br /> Signature of Property Owner Date <br />