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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Prujc r,i Numb�r. _ _ (Cify fo Proi-ide) <br />Please complete both s+ides of the form <br />Property Owner Section: <br />� Property Owner Name: Sr �U.eOu,.�/� <br />I Installation Address: .� 7 G��'t'�"� �f`e' <br />aiy �,ae � Slate: lc.�� _ Zip .`/� 2-�' � <br />Mailing Address (i(dif(erenf): __ <br />City: State: Zip: <br />[mail: ��boNav�w,g- �/}0� CO+� __Phonr.(j5rj} "z-�Z—�l/� i <br />Total Cost to Insiall Device ((�om contrector invoiceJ: 5_ o�� C1 � � <br />------------- — �� <br />I, the property owner, request to have if�.e Cd� of Everett Back�vater Prevention Device rebate check <br />for the installalion of liie devicc at the above referencea properly address be made payablc to, and <br />senl lo, the vendor speci8ed on �he b�ck of lhis form. By requesting the rebatc check be made <br />payable to the vendor, I agr2e lo the follo�vir�y: <br />1. i will nol recewe a rebale check drteclly from the City of Fverelt <br />2 Assignmg paymr.nt o( the rebate to the vendor docs not exempt n,e trom [3ack�•,ater <br />Prevention Device Rebale Program requiremeMs. <br />I aulhorice Ihe release of my rebatc to �he vendor lis�ed on Ihe bar.h nf this (oim pending <br />approval of Ihe completed Back�•�aler PievenUon Device rebale oacket by lhe Csry of Fverett <br />�� ',�%� _ �T�'�(%�� <br />Signature of Property Owner Dale <br />