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1 <br /> � Backwater Preventiun Device Rebate Pro,yram i <br /> rr Vendor Payment Option Form ' <br /> Pro�ect Number (Ci7y fo Providel � <br /> i <br /> i <br /> Please complete both sides of the form � <br /> i <br /> Property Owner Section: � <br /> PropeAy Owner Name �/`1 /'� � L -------_ _...__ <br /> Inslailation Address _L ? L /� L ]� C� V 'L � <br /> 1 �' _K - - -- I <br /> � <br /> � - � ��{ � �� � � <br /> Cily: ��'l:.k � ' 1---- _. State ��/�._--- Z�P'—. <br /> Mailing Address(i!dillcrent) ____ <br /> � City — -- State: _ _Zip i <br /> I Email a� i���� e � G,�r t��� �il n.-{ ��� , k,����� Phone (�115) S3 �. �, .5}-��_ , <br /> I _ <br /> �T otal Cost fo Install Device ((rom contracfor invorcoJ 5 __2��'�' .• G:� � <br /> .- - --- - -- - - -- ---- - --_ ----- - . i � <br /> L lhe property ov✓ner, reyuesl to have ihr. Ciry nf Everett Backwater Prevention Device rebate check <br /> for the installation ef the Ar.vice al ihe above referenced property address be made payable to, and ; <br /> sent to, Ihe vendor specif�ed on the har.k of this foim By requesling the rebale check be made <br /> payahle to lhe vendoi, I ayrce to the`ollo�vmy <br /> 1 I �vill not recewr, a rebafe check directly from Ihe City of Everel� <br /> 2 Flssignmg payrnenl o(ihr. reb:�te lo the vendor does not exempl me hom Backwalr.r � <br /> Preventiun �rvicc Rebate Program requirements � <br /> I authonze the releasr, of my rr.bate ro the vendor bsted on the hack of this form pendinr� <br /> �ppiooal of the completed Backwater Prevenhon Device rebale packel bv Ihe Cily oF EvereU ; <br /> � <br /> � �f - i� lS <br /> Signaturr, ol Property Owner Date <br /> � <br /> � <br />