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Backwater Prevention Device Rebate Program <br /> Es. rr Vendor Payment Optic�n Farm <br /> Project Number: ___ (Cify fo Provide) <br /> Please completc both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ����R � _C� 1 SLG <br /> InstallationAddress: Ao� �o��n� <br /> I <br /> CitY:�,�(,n �,gkk- State: V�d� Zip: ��"J'2-o�' � <br /> Mailing Address (if diHemntJ: �� �fi I <br /> City: State: Zip: <br /> Email: Phone: ( ) <br /> Total Cost to Inslall Device.(lrom contractor invoice): $ _ <br /> I, the property owner, request to have the City o(Everett Backwater Prevention Device rebate check <br /> for the instalialion of the device al lhe above re(erenced property address be made payable to, and <br /> seN to, the vendor specified on the back of this form. F3y requesting the rebate check be made <br /> payable to the vendor, I agree to tha following� <br /> 1. I will not receive a rebale check directly trom ihe City of Everett. <br /> 2. Assigning payment of lhe rebate lo lhe vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requiremenls. <br /> I authorize Ihe release of my rebate to lhe vendor listed on Ihe back of Ihis form pending <br /> approval of the completed Oackwaler Prevention Device rebale packet by the Cily of Everelt <br /> elaW. 1� \ 5�-- 1 y - 1 S <br /> Sig�ature o(Property Owner Date <br />