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Backwater Prevention �evice Rebate Program <br />Vendor Payment Option Form <br />Projecl Number: (Cify fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: �sp n�� ���,,�✓rt/ <br />InslallalionAddress: �]r2 Z lti 1�(����-U-� _ <br />r <br />City: � u�/J-2 � State� j��13�_ 2ip: � I-1 D��: <br />Mailing Address (ifdifferent): <br />City: State: 2ip: <br />Email: �,,,,�,�� S$ �i'� t�,1A,s'�u �_(�.u� Phone: (r{j51 _:?-S'�/ •'�g� <br />•--� <br />Total Cosl to Inslall Device (from contractorinvoiceJ: 5�a . 3q <br />I, the property owner, request to have lhe City of Everell Backwater Prevention Device rebale check <br />for Ihe installation o( the device at the above referenced property addrnss be made payable to, and <br />sent to, lhe vendor specitied on the back of lhis form. [3y requesting the rebate check be made <br />payabte lo Ihe vendor, I agree to the following: <br />1. I will not receive a rebate check directly from the City of Everett. <br />2. Assigning�payment of the rebate lo lhe vendor does not exempl me from [3ackwater <br />Prevenlion Device Rebate Program,requirements. <br />I aulhorize the reiease ot my rebate to lte vendor listed on Ihe back of this form pending <br />approval of Ihe completed Backwater Prevenlion Device rebate packet by the City of Everett <br />Z �- Z '" ZO/_ S <br />Date <br />