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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (Ciry fo Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: M R�-i� �ho�5 rn <br /> Installation Address: ,,_f W �- �'� h �T�' <br /> Ciry: �re-� Slata: WA Zip: � �'a-� � <br /> Mailing Address(i(diHerenfJ: <br /> City: State: ZiP: <br /> Email: M�h K� �^1i�� u titi`° • !�1''� Phone: (y�J �-52-�b �' � <br /> � <br /> Total Cosf to Ins;all Device (from contractorinvoice): 5 �2`ZC� •�— <br /> I, the property owner, request ro have Ihe City of Everett Back�vater Prevention Device rebale check <br /> for lhe installalion o(the device at the above referenced property address be made payeble lo, and <br /> sent to,the vendor specified on lhe back oi this form. By requesling the•rebate check be made <br /> payable to the vendor, I agree lo lhe tollowinc�: <br /> 1. I will not receive a rebate check directly from the City of Everett. <br /> 2. Assigning payment of the rebale lo the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> I aulhorize ihe release of my rebatc to the vendor listed on lhe back of Ihis form pending <br /> approval of lho completed Backwaler Prevenlion Devite rebate packet by Ihe City of Everett <br /> 'f / a �ls <br /> Sign tr�re of ropert wner Date <br />