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i <br /> - r 17. 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: viir INLA outy- . , k... <br /> Installation Address: LI 1-4- kAla..tk- <br /> City:—: -0 State: WA- Zi,p: 9D-c I <br /> Mailing Address(if different): <br /> City: State: Zip: <br /> Email: Phone: ( ) <br /> 0__-- <br /> Total Cost to Install Device (from contractor invoice): $ AC,.3- -.1-71----- <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 fomi. 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 /> --.:1- • 1 V I -2---- '2-7- I A-- <br /> , t <br /> Signature Of Prope rawner Date <br />