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B�ckwater Prevention Device <br /> E� Rebate Pragram � <br /> � <br /> � <br /> For interna! Use: Projc�ct Numbcr: <br /> Vendor P�ymen� Option Form <br /> Please complete botf� sides of the form <br /> F'roperty Owner Sectian (please print): <br /> �.��::�t���l- ���-�-����-�-�- <br /> ---------- --___. <br /> __---___ --- <br /> Pr�operfy Owner N�me <br /> a�:�.�'� �����e���F�-��� �`��,�,�'"_ <br /> __--------------- -- ._�_�____.. <br /> Property Address City State Zip <br /> � <br /> _.-----_— p��..._ �_..__--_ <br /> Altemate Mailing Address City State �� <br /> Phone z�f�'. ����---���;�� T Email � <br /> I, the Praperty Owr�er, request to have the Gity of Everett B�ckwater Prevenfioi� Devicc� <br /> rebate check for the installetion referenced at the Pro��erty Address be madc� payable <br /> to, and sent to, the Vendor. By requesfir�g the incentiv�/rebate check be made �aayable <br /> to the Vendor, I agree to the foilowing: <br /> 1. ! will not receive a Backwater Prevention Device rebate check directly From ihe � <br /> City of Everett. <br /> 2. Assigning payment of the Backwater Prevention Device rebate to the Vendor <br /> does not exempt me from Backwater Prevention Devic� Rebate Program <br /> requiremenfs. <br /> ! authorize the release of my rebate to the Vendar listed on p�ge two of t}�is fc�rm <br /> pending approval of the coinpleted Sackwater Prevention Device rebate par,kage by <br /> the City of Everett <br /> �' • �t �.� <br /> �--- <br /> � r�at�- of Property Owr�er Uate <br /> Page 1 of 2 <br /> Revised 9/3/7_014 <br />