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� Backwatsr Prevention Device F2ebate Program <br /> Vendor Payment Option Form <br /> F'rn�er.f Number -- — lCrty fo Pmvide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property O�vner Name .�O�JA�p � DF.3GI�f1N_ �AKF)SN �'�A._.__ ___ i <br /> Inslalla!�on Address �(cC>,�.I{�ST,UUT 5 T i <br /> C�IY __�V£.(2�TT __ S17tP �A__.__ 7ip��c�� � _ I <br /> '.:a�ling Address (dU�ller�nf) 5 P1M� __ I <br /> c�ty state Z�� <br /> i Email b UAKnSHIrn� (� FRO�J���TZ•Wt•1 Phone (�lati)_.5Y3 -�04�`�-- <br /> � Total Cost to Install Device (lrorn conhactoi rnvorcel. S�L61�,_�_ . _ _ ���. . � <br /> I, Ihe propert� o�vner. request to have Ihe Gdy ol Fverett Ci�ckwater Prevenlion Device rebate check I <br /> for the installahon of the device at Ihe above relerenced property address he made payahle to ann <br /> senl to, lhe vendor specdied on Ihe back o!this form Hy requcsling lhe rebale check be made <br /> pa��able tn Ihe vendor, I agree to the follo�ving <br /> 1 I rnll no! recerve a rebate check direclly (iom the City of Everett <br /> ? Assigniny payment of lhc icl�ale to thc vendor dnes not c�emp! mu frum Hackv�atcr <br /> Prevention �evice Reba�e f'iu��am icyunemen�s <br /> --- - - i <br /> i authonie the ielease ol nry rebale lo the vendur listed mti the back ol Ihis laint pendmy <br /> ,vpproval ot thr. completed Har.kwater Prevent�on Dewce rebale packet by the C�ty of Cverett <br /> �����ca�_�l)��F��nt'�.n�.n- -- -- C—�i'��I`J <br /> Signature of Properiy Owner Date <br />