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��, <br />Backwater Preverition Device <br />Rebate Program <br />Fat ir�temal Use: Projed Numbcr: <br />Vendor Payment Opi�ion Form <br />Please complete both sides of the form <br />Prc�erty Owrter Secti�n (rlease print): <br />Pfoperty Owr��Name � <br />.3��1:,:r/�.�,zzc^4�.�i�. _����� , c _ <br />Property Address ��v S 3te Zip <br />, 39 l .��a no o _ '`/0T� , f ('� S� __ <br />Alternale Mailing Address �ity' I State Zip <br />7�� :�37—h�/��D i;;,i�Ci.f3c� � OM ei �. �� �, Hl <br />Phone Email <br />I, the Property O�mer, request to have the Ciry oi Everett Backwater Prevention Device <br />rebate check for the installation referenced at the Property Address be made payable <br />to, and senl to, the Vendor. By requesting the incentive/rebate check be made payable <br />to the Vendor, I agree to the following: <br />1. I will not receive a Backwater Prevenlion Device rebate check directly from tlie <br />Cih� of Everett. <br />2. Assigning payment of the Backwater Prevention Device rebate to the Vendor <br />does not exempt me from Backwaier Prevention Device Rebate Program <br />requirements. <br />I authorize the release of my rebate lo tl�e Vendor listed on page hvo of this form <br />pending approval o( ihe completed Backwater Prevention Device rebate package by <br />the Gity of Everett <br />� ��q <br />�' <br />��-��i✓�_^[JJ �'�i,�,.� /z�irJ�Af����---" i1 -/ ? ' � U l S <br />Signature of Property Owner <br />Fevised 913I2014 <br />Datc <br />Page 1 of 2 <br />