Laserfiche WebLink
I <br /> I <br /> 1 <br /> 1 <br /> #1111ah. Aori.al <br /> P Backwater Prevention Device <br /> Togipi n Rebate Program <br /> I <br /> I <br /> For internal Use: Project Number: i <br /> Vendor Payment Option Form <br /> Please complete both sides of the form <br /> Property Owner Section (please print): <br /> 71. /5 en va- <br /> Property Owner Name <br /> f70.,. (ems/ sr, "p, IA . q &eoe <br /> Property Ad ress ,, 1 Cit _ <br /> State <br /> vte J z 7 i <br /> Alternate Mailing Address City State Zip <br /> 14.... ..5"-,meq 13 V 3 000 450 8ilgAger) kPAS1/11.cdm <br /> Phone Email <br /> I <br /> I, the Property Owner, request to have the City of Everett Backwater Prevention Device <br /> I <br /> rebate check for the installation referenced at the Property Address be made payable <br /> to, and sent to, the Vendor. By requesting the incentive/rebate check be made payable <br /> to the Vendor, I agree to the following: <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 <br /> does not exempt me from Backwater Prevention Device Reba:e 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 /> 3 <br /> I& AA �,, /.,;Z. -5--ill <br /> Signal- re of Property 'I wner Date <br /> I <br /> I <br /> Revised 9/3/2014 Page 1 of 2 <br /> k <br />