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r-lease C01i-pete uuth sit--,rs oI L ivir�i <br />Property Owner Section, <br />Property Owner Name: &.sr�� <br />Installation Address: <br />City: State: <br />Zip:-..j <br />Mailing Address (if different). <br />City: State: <br />Zip: <br />Email: A L? G- Phone: <br />Total Cost to Install Device (from contractor invoice): S -W, <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, 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 />I 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 />i <br />! <br />Signature of Property Owner <br />Date <br />i <br />