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Back�nrater Prevention Device <br />Rebate Program <br />For internal Use: Project Number: <br />Venc�or Payment Option Form <br />Please complete both sides ot the form <br />Property Owner Section (please print): <br />�� ,� �� ---- _ - - <br />Property ONmer Name <br />�o�i f8't`'` S_r Sv�,r�- c.J4 _ att�r <br />Property Address City State Zip , <br />lllternate Mailing Addrec City Slate Zip <br />` <br />F'hone <br />Email <br />w <br />I, the Property O�vner, request to have the Cily of Everett Backv✓ater Prevention Device <br />rebate check for ihe installation referenced at the Property Address be made payable <br />to, and sent 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 Prevention Device rebate check directiy from the <br />City of Gverett. <br />2. Assigning payment of the Backwater Prevention Uevice rebaie to the Vendor <br />does not exempt me from Backwa?er Prevention Device Rebate Program <br />requiremants. <br />I authorize the release of my rebate to the Vendnr lisled on paye fwo of this form <br />pending approval of lhe completed E3ar,kwater Prevention Device rebate package by <br />the Ciiy of Everett <br />�9'/� _ <br />S ature of Propeity Owner <br />_3�/��s _ <br />Date <br />Page 1 of 2 <br />Revised 913/2014 <br />