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Backwater Prevention Device Rebate Program ,�
<br /> la/ Vendor Payt�lent option Form ,., ''',:,:.,,,,,,,,,,,,,i',11.',,,4,,,,,,,
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<br /> ( -iProject Number: (City to Provide)
<br /> Please complete both sides of the form
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<br /> Property Owner Section:
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<br /> Property Owner Name: , ,, #_ r; ,, Y , ,,qtr
<br /> Installation Address: 1,..)1-7,
<br /> City: tf,lie le 1—'-- State: '4 Zip: ---e't
<br /> Mailing Address (if different):
<br /> City: State:
<br /> Zip:
<br /> F,, 1
<br /> Email + .. ' r, Phone i ct I
<br /> Total Cost to Install Device (from contractor invoice): $ ,5- - -----
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<br /> I, the property owner., request to have the City of Everett Backwater Prevention Device rebate check Yd"
<br /> for the installation of the device at the above referenced property address be made payable to, and
<br /> sent to, the vendor specified nn 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 A
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<br /> Signature of Property Owner Date
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