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: �Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />' Projecl Number. (Ciry fo P�owdo) <br />Please compiete both sides of the form <br />Property Owner Section: <br />Propetty UNner Name: ���c���--y <br />Installalion Address ��_li,���� _ _ <br />city�Z.� \ 1 state: W A zip� �Zi� I <br />Mailing Address (i! di/lefsnf): <br />City� Stele: Z�p' <br />Email: MCI��C�J\�A 1��—���_�L.�C�Phone: (�i�2���� I L <br />Tatal Cost to Install Davice (lrom cm+trador �nvoice)� 3 �( 4� �.�X <br />I, lhe propedy owner, mquesl lo have the City of Everelt Dackeiater P�eveNion Device rebole check <br />fa thn Inst311ation of the device at thc ahove refcrenced property addmss be made payaUle to, and <br />sent lo, tne vendor specif,eA on the back of this fortn. 8y reques6ng the rehale theck be madc <br />payable lo the vendor, l agrec to Ihe following: <br />1. I will not recelve a rebate check direclty from lhe Cily oF Evereit <br />2. Assigning paymeot of the rebale lo lhe vendor does nol exempt me 6om Back�valer <br />Prevenlion Device Rebate Program requlrements. <br />I authodze lhe release ol my rebate to Ihe venAor li,ted on thc back af this lorm ponding <br />approval ot lhe complcled Backwaler PrevenG�n Dovioo rebate packet by ihe Ciry ol Everelt <br />. <br />�� / / �i�t ' ,� 2�" � <br />i <br />Sipnalure of Property Owner Dale <br />