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t <br /> i <br /> i <br /> i <br /> i <br /> i <br /> i <br /> 1 <br /> 1 <br /> Backwater Prevention Device Rebate Program <br /> 4E. Vendor Payment Option Form <br /> # <br /> i <br /> Project Number: (City to Provide) <br /> I <br /> Please complete both sines of the form <br /> Property Owner Section: <br /> i <br /> Property Owner Name: �CW► �i7LG(,( i - 1 <br /> x <br /> Installation Address; 1 <br /> City:_.--leM State: <br /> - Zip: Qom/ <br /> Mailing Address(if different): <br /> City: <br /> State: Zip: <br /> 1 Email:1046h/ILiM a,IaN- (NtQc �p <br /> j g Phone: (t(o 3 J��CJp 1 <br /> Total Cost to Install Device (from/ contractor invoice : S 9 <br /> I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check 1 <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 <br /> payable to the vendor. I agree to the following: q 9 the rebate check be made <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 F <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my rebate to the vendor listed on the hack of this form pending <br /> 1 <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> . F <br /> F <br /> a4v% / K 1 <br /> ,540//5i <br /> Signature of Property Owner i <br /> Date , <br /> x <br /> I <br /> °s <br />