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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> Please complete both sides i),f thoform <br /> ?Property Owner Section: <br /> Property Owner Name: Du) L • <br /> Installation Addrcso: C 6 L /)-1&-- <br /> city: fitterA-- state, <br /> :- <br /> Mailing Address(if different): (-3-) 6 I <br /> - <br /> aty: state: p: q j6ail: ? <br /> rri.criz-Lice_FrterA fe4)-^Phone:( ll - 3i 2-3-3 <br /> eTotal Cost to Install Device(from contractor invoice):$ "381 9-3)-- <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,the vendor specified on the back of this form.By requesting the rebate check be made <br /> payable to the vendor, agree to the following: <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 authorize the release of my rebate to the vendor listed on the back of tits form pending <br /> approval of the completed Backwaterrenlion Device rebate packet by the City of Everett <br /> y <br /> SgnatureofPmPe Owner Date <br />