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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: __ (Ciry to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />PropeAy Owner Name: <br />� 3 G � l,� �. <br />Inslallation Address: �,e R f✓I Lc <br />Ciry: �✓��-" Slate: �A Zip:� �� o I <br />Mailing Address (d diNerent): <br />City: <br />Slate: <br />� <br />�/ 10 <br />Email: n�o G !,/� r� _��.4er✓,���. Ccm .Phone: (`�s d-b � 01 <br />^ ��j O <br />Tolal Cost to Install Device (lrom contraclor invoice): 5 r}-��� ' <br />I, lhe property owner, request lo have the City of Everelt Backwater Prevention Device rebate check <br />tor the installation oi lhe device at lhe above referenced properly address be made payable to, and <br />sent lo, the vendor specified on the back of this torm. By requesting the rebale check be made <br />� payable lo lhe vendor, I agree lo lhe (ollowing: <br />~� 1. I will not receive a rebate check directly from the Cily of Everett. <br />2. Assigning payment of the rebate to the vendor does nol exempl me from Backv�ater <br />; Prevention Device Rebale Proc�ram requiremenls. <br />I aulhorize Ihe release of my rebate to Ihe vendor listed on the back of this form pending <br />approval of the completed Backwater Prevention Device rebate packet by Ihe City oi Everett <br />of PropertY Owner <br />1�3r5�" <br />Dale <br />