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44.010,i.A.- 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 /> Property Owner Name: � R 6 /1 A (2 r/ <br /> ins" <br /> Installation Address: / . 0 ( ( f 5� J 'tr <br /> City: tJ.e /i- State: (JV PC Zip: <br /> Mailing Address(if different): <br /> City: State: Zip: <br /> Email: Phone: 4� �� " 64 <br /> Total Cost to Install Device(from contractor invoice): $ <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 /> jina 1V41-4.43 /02°1 /I/7 <br /> Signature of Property Owner Date <br /> 4 <br />