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Backwater Prevention Device <br /> 4L Rebate Program <br /> For internal Use: Project Number: <br /> Vendor Payment Option Form <br /> Please complete both sides of the form <br /> Property Owner Section (please print): <br /> Property Owner Name .� <br /> Property Address City W State Zip <br /> Alternate Mailing Address v City State Zip <br /> _� - t <br /> Phone Email <br /> 1, the Property Owner, request to have the City of Everett Backwater Prevention Device <br /> rebate check for the installation referenced at the Property Address be made payable <br /> to, and sent to, the Vendor. By requesting the irice ntive/rebate check be made payable <br /> to the Vendor, I agree to the following: r <br /> 1. I will not receive a Backwater Prevention Device rebate check directly from the <br /> City of Everett. <br /> 2. Assigning payment of the Backwater Prevention Device rebate to the Vendor i <br /> does not exempt me from Backwater Prevention Device Rebate Program <br /> requirements. <br /> I authorize the release of my rebate to the Vendor listed on page two of this form <br /> pending approval of the completed Backwater Prevention Device rebate package by <br /> the City of Everett <br /> Signature o 1roperty Owner Date <br /> "��+�•.......v. <br /> Revised 9/3/2.014 Page 1 of 2 <br />