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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Prejecl Number __ (City to Provide) <br /> Please complete both sides of the fo�m <br /> Property Owner Section: - <br /> ---- � <br /> Property Owner Name: !,� � �`� � ���LO K i <br /> I <br /> Instatlation Address / �6 / �D �b�/ i <br /> City: Cv t�� state: ��- zip: � �"d0 J I <br /> Mailing Address(if dilferent): I <br /> City: State: Zip: I� <br /> Email. ALONfi iY! 3 C. C�M�+i� , �o�l Phone: ( `� as�- 9�,.i� i� <br /> Total Cost to Install Device(Irom confractor invoice): 5�t S� r� _ <br /> I, Ihe property o�vner, requesl to have lhe City of Everetl Backvrater Prevenlion Device re6ate check <br /> for the installation o(lhe device at the above referenced property address be made payable to, and <br /> sent to,the vendor specified on Ihe back of this (orm. By requesling lhe rebate check �e made <br /> payahle to lhe vendor, I agree to the tollowing: <br /> 1 I will nat receive a rebate check directry from the City ot Eveiett <br /> 2 Assiqning payment o(the rebate to lhe vendor does not exernpt me from Backwater <br /> Pi�veNion Device Rebale Program requirements. <br /> I I authorize the release oi my rebale to the vendor lisled on Ihe back oi Ihis (orm pending � <br /> � approval ol lhe compleled t3ackwater Prevention Device rebale packel by lhe Cily of Fverett <br /> I <br /> � <br /> /J'/ �Vc,t�.l�i�c-.�._ /���/J <br /> Signah o Property Owner Date <br /> -- -- -- — - - --- -----� <br />