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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> f <br /> Project Number: (City to Provide) <br /> 3 <br /> 3 <br /> i <br /> Please complete both sides of the form <br /> Property Owner Section: r <br /> f <br /> g <br /> PropertyCJwner Name:- i 4'1 i <br /> Installation Address: �.- <br /> City: � State, Zip- <br /> Mailing Address(if different): <br /> City: State: Zip: x <br /> np q j <br /> Email: Elvis" <br /> 'a �L b ^rhone: ( ) <br /> Total Cost to Install Device(from contractor invoice): $ <br /> r <br /> I,the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at the above referenced property address be made payable to, and <br /> sent to,the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: i <br /> 1- l will not receive a rebate check directly from the City of Everett. I <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my rebate to the vendor listed on the back of this form pending <br /> approval of the completed Backwater Prevention,Device-'rebate packet by the City,of Everett <br /> W� � 1 �k <br /> sign -Property Owner Date <br /> i I <br />