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i <br /> I Backwater Prevention Device Rebate Program <br /> I <br /> I Vendor Payment Option Form <br /> , Pro�ed Number. ___ ___ (Cify fo Provide) <br /> � <br /> Please complete both sides of the�orm <br /> Property Owner Section: <br /> � Property Owner Name•�L}�i'�_ �1.�--- --- — � <br /> IInstallatlonAddress' _ 2`�� �L�V�j6a .?��VD______ <br /> , City' _ _ G �.1�.�TZ--Statc: �� —Zip: 4 �� 1 <br /> Matling Address(il dilforent): <br /> City: Slale: Zip: <br /> Email: i Phone: ( ) <br /> Total Cosl to Install Device(liom con7actor invoice): $__�rj� � <br /> , -------- --- -- <br /> I, the property owner, requesl to have the City of Everett Backwater Prevention Device rebate check <br /> for the inslallation o(the device al the above referenced property address be made payable to, and <br /> senl to, the vondor specitied on lhe back of this form. 8y requesling the rebale check be made <br /> ' payable to lhe vendor, I agree to tha following: <br /> � 1. I wdl not receive a rebale check dimclly from the City of Evorell. <br /> 2. Assic�ning paymont ol the rebala lo�ho vendor does not ezempl me from Backwater <br /> Prevention Device Rebale Program requiromants <br /> I —__ - _._ _ _ _ ___ - _ -- - -- <br /> I authorize ihe release of my rebale lo the vendor listed on the back of this lorm pendmg <br /> � approval of the complulud Backwaler Prevenlion Device rebate packel by lhe Cily ot Everett <br /> I � - <br /> ' D 7Al <br /> Signature of Property Ownor Dale <br /> � --------- -- --- -- <br /> � _ . . . <br />