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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Pioject Number: (Cify to Provlde) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> PropeAy Owner Name: c�(l��'Y��`� ��Q-✓<<� <br /> Installation Address:�w �� �'O'� ►�'� `�"� <br /> City:,�(_PJ✓—'e.� State� .�J.)�_Zip: � ' <br /> Mailing Address(ildiHerenf): _ <br /> ��ty: Stale: Zlp: <br /> Email: AAa 1�•�hone: (��'� U I� �Z��' <br /> Total Cosl to In�(Irom contracrorinvo'c 9):S a4�.9� <br /> I,Ihe propeAy owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at the above relerenced property address be made payable lo,and <br /> sent,c. the vendor specified on the back ollhis lorm. By requesting the rebale check be made . <br /> payable!- 'he vendor, I agres lo the(ollowing: <br /> ' �riill not receive a rebale check directty fmm the Gty of Everelt. <br /> 2. P,ssigning puymenl ot the rebate to the vendor does not exempt ma from Backwaler <br /> f�revention Device Rebate r`�ogram requirements. <br /> � � <br /> I authorize the rele of my rebate to ihe vendor listed on ihe back of this fo�rt.pend�ng <br /> epprov the co p ted Backwater Prevention Device reoate pecket by lhe Cily of Everetl <br /> � <br /> Signature of roperty Owner Date <br />