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3v <br /> 0j,677. <br /> Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> { <br /> Property Owner Name: .„! -s' --in, <br /> Installation Address: 2110 ' .' Cob"I <br /> City: lj State: 114 Zip: l 0 <br /> Mailing Address (if different): 2. tj---- ‘--- c- 111- 1- 6__ .E.,________ <br /> City: -2ire. State: -►4 Zip: 9r2-0S-- <br /> Email: <br /> t0Email Phone: ( ) Sa i °- c)0 0 O <br /> c�, <br /> Total Cost to Install Device (from contractor invoice): $ 14t LI1 - ±9--- <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 myrebate to the vendor listed on the back of this form pending <br /> P g <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> 6-P/P 8-1q-- iS <br /> Signature of Property Owner Date <br />