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Etadk�v ter <br /> Vendor Payment Option For <br /> Project Number: _ (City to Provide) <br /> Please c th sides of the form <br /> i <br /> Property Owner Section:,'' <br /> Property Owner Name: <br /> Installation Address. <br /> t .I�" _�'� . fit Stater Zip: <br /> Cit i <br /> y. <br /> Mailing Address (if di ferent): t-f a �", <br /> city: .>t ,` State to Zip: 9(6-2k,2-3 <br /> Email: ke� <br /> OkC (:L.YV> a a- t '>l Phone, t t <br /> Total <br /> Cost to Install Device {from contactor invoice): $ � <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,thevendor 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. 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 /> WI <br /> 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 /> U <br /> Signature of Pro Owne Date <br />