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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (City to Provide) <br /> t c„ <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: <br /> Lk\ el <br /> installation Address: t?t) I Cie <br /> City:' - State: a- - Zip: 93(boio. <br /> Mailing Address(if different): <br /> City: State: Zip: <br /> Email: )474--444416k114. it(283(?6714114/414 Phone: A ;#7— b/2 <br /> 0/00 <br /> Total Cost to Install Device Vmm contractor invoice):$ 3b <br /> I,the propertyowner, request to have the City of Evereft 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, 1.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 /> 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 /> 6. IL:, <br /> cc-25C \(b. <br /> Sign. r- of Property Owner Date <br />