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Bar,kwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> i <br /> Project Number ____ (City lo Provide) <br /> Please complete bolh sides of the fc�rm <br /> Property Owner Section: <br /> - -- --- — � ----- <br /> Property Owner Name: � �'1��,�,������ �� � S- <br /> Installalion Address: (� I�� ��.�..k� � -�✓`� _ <br /> City' �f/�/�.{��"� State: 11� Zip � �c3U� <br /> Mailing Address (il dit(erentJ: <br /> ; City:_ Stale: ------- Z�p'------------ - <br /> Email: --- .-- -- ---- - - Phone: ( ). - ----- — <br /> Total Cost to Install Device (lrom confracforinvoice) $���>_, ' LJC> _ _ <br /> I, the property o�vner, request to have Ihe City of Everett Back�vater Prevention Device rebate check <br /> for the installation of lhe device al�he above ie(erenced property address be m�de payable�o, and <br /> sent to, lhe vendor speafied on lhe back of this form. By requesting ihe rebale check be made <br /> payable to the vendor, I agree to the following: <br /> 1. 1 wdl not receive a rebate check direclly from the City of EvereQ <br /> 2. Assigning paymenl o(the rebale to the vendor does nol exempt me from Back�valer <br /> {'reven6on Dewce Rebate Program requiremenls. <br /> I authorize Ihe release ot my rebate to the vendor listed on the back of this (o�m pending <br /> approval of ihe completed Dackwater Prevenlion Device rebate packet by the City of Everett <br /> : �/ <br /> ��i�' �u� L� '? _�--�— <br /> Signature of Property.Owner Dale <br />