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4 <br /> Bachwater Prevention vacProgram <br /> Vendor Payment Option Form <br /> Project Number. (City to Provide) <br /> P'lease complete both sides of the form <br /> Property Owner Section: <br /> i <br /> i <br /> Property Owner Name: {= i <br /> f <br /> Installation Address: <br /> � <br /> pp <br /> City: ... State: ._ Zip_ I 0 <br /> Mailing Address(if different): <br /> City: State: Zip: <br /> Email: Phone: ( ) <br /> Total Cost to Install Device(from contractor invoice): $ ` Po <br /> 1,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: <br /> 1. 1 will not receive a rebate check directly from the City of Everett. <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 /> Signature of Property Owner Date <br />