Laserfiche WebLink
l <br /> Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> f <br /> Project Number: (City to Provide) <br /> 1 <br /> J <br /> } <br /> Please complete both sides of the form <br /> } <br /> Property Owner Section: <br /> 6. <br /> G <br /> Property Owner Name: <br /> �2— 3&lh <br /> installation Address: <br /> �� f State: L�. Zip: <br /> City: a <br /> Mailing Address(if different): r <br /> City: State: Zip: <br /> Email: <br /> Total Cost to Install Device(from contractor invoice): $ <br /> 1, the property owner, request to have the City of Everett Backwater PrO-Vktion Deirice 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 /> l <br /> I_ I 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 <br /> I authorise 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 /> z { <br />