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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. (City to P�ovide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Properfy Owner Name: � c�n n �, f1C� !7 _ <br />Installation Address: _�� � <br />Cily: �U P.►'�,�_ State: <br />Mailing Address (il diNerenf): ��--�-�� <br />City: <br />Email: <br />State: <br />Total Cost to Instail Device (from conlractor invoice): $ <br />Zip: '�J �i�-U� <br />Plione: ( ) <br />I, lhe property owner, request to have fhe Cdy oi Gverefl 13ackwater Prevention Device rebate check <br />for the installalion o( the device at Uie above referenced properly address be made payable to, and <br />sent lo, lhe vendor specified on the back of lhis form. By requesling ihe rebate �he�k be made <br />payable to lhe vendor, I agree to the following: <br />I e�ill not receive a rebale check directly from the City ot Evereti. <br />2. Assigninc� paymenl of the rebate lo lhe vendor dnes not exempl me irom Back�vafer <br />Prevention Devicr. P.abate Rogram r�quiremenls. <br />I au[horize the release of my rebate lo lhe vendor listed on the back of this form pending <br />approval of the complelr,d fiar,kwater Prevention (]evir,e rebate packr.t by thr. Gty oi F_verett <br />-- � <br />Signature of Properly Owner <br />