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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Number:_ (City fo Provide) <br /> Please complete both �ides of the form <br /> Property Owner Sectfon: <br /> Property Owner Name: _��, ..o._ �y���-I- <br /> InslallalionAddress: (5b �. �j�lre. Qu�. <br /> Cily: (�vu�1 State: �w�A Zip: CIB 7.0 1 <br /> Mailing Address(i/dillerenl): <br /> City: State: Zip: <br /> ---._ _ _ . _._ -------- --_ _^ �___.._.-------------- ----_-__.. _ _. ._. <br /> Email: Su.�an���.��F-1 �. be�.�,a�l .con, _ Phone: (l.(�'�j �52 -77�_ <br /> Total Cosf lo Install Device (Iroin confractorinvoico). $ oC�,3l •� � <br /> I, the property owner, request to have the Cily o(Everett Backwaler Prevenlion Device rebate check <br /> for the inslallation ef the device at the above referenced property address be made payable lo, and <br /> sent lo, the vendor specified on the back ol this form. By requesting lhe rebate check be made <br /> payable to ihe vendor, I agree to the following: <br /> 1. I will not receive a rebate check dlrectly Irom Ihe City of Everett. <br /> 2. Assigning payment of the rebalQ to the vendor does not exempt me from Backwater <br /> Prevention Davice Rebale Program requirements. <br /> I aulhorize the releaso o(my rebate lo Ihe vendor Gsled on the back uf this form pending <br /> approval ol Ihe compleled Backwater Prevention Devlce rebate packet by ihe City ot Everett <br /> 3- 9- i5 <br /> Signature of Property Owner Oate <br />