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Backwater Prevention Device Rebate Program <br /> Vendor Payment OpYion Form <br /> Project Num�er: _,__ (City fo Provide) <br /> Please camplete both sides of the form <br /> Property Owner Section: <br /> Properly Owner Name: '/ �� I-J�'� 4� I�/�S - --- — <br /> Installation Address: � ( ,C��S� I�� � <br /> City:_��Qir.Q�� Stale:.Wf� Zip: '^I u�.7 <br /> �vlailing Address(il diI(erant): <br /> City: Slate: Zip: <br /> Email: Phone: ( ) <br /> Total Cost to Install Device(from confrecfor invoice): $ ____ <br /> I, the property owner, requesl to have the Cily of Everett Backwater Ptevention Device rebate check <br /> for the installation of the device at the above reierenced property address be made payable to. and <br /> sent lo, the vendor specified on the back of this form. By requesting the rebale check be made <br /> payable lo the vendor, I agree to the following: <br /> 1. I will not receive a rebale check directiy from the Ciry of Everett. <br /> 2. Assigning paymenl of lhe rebate to the vendor does not exempt me(rom Back�vater <br /> Prevention Device Rebale Program requirements. <br /> I authorize the release of my rebate to the vendor listed on Ihe back of this form pending <br /> approval of Ihe compieted Bar.kwaler PrevenUon Device rebale packet by ihe City oi Everell <br /> l L�'�f ��1�'� 3 I�. 15 <br /> Signature of Property Owner Date <br />