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Back�,nrater Prevention Device Rebate Program <br />�v Vendor Payment Option Form <br />Fro�ect Numher _ _ (Crt, to P, n�ide) <br />Please complete both sides of the form <br />Property Owner Section: <br />i_ -- — -�_ <br />Propert� Owrer Name: _ �-•,��� <br />Installation Address: __� �'� <br />� <br />CitY' _'���� 5 <br />Iviading Address (i(difterenf): <br />i City. <br />-�� � ��-,�,� � _ I <br />/'] , � <br />tate: —� --- Zip: `'i __� ( _ ' <br />State <br />Email: C�G�_f����{;,Y%-��'�`.1'�'J Phone (�-��-G�1- ' <br />Total Cosl to Install Device (from contracfor �nvoice) 5�� U _ <br />I, lhe property owner, requesl to have the City of Everett Backvraler Prevention Device rebate check <br />for the instaltation o( the device at the above referenced property address be made payable lo, and <br />sent to. Ihe vendor specified on the back of this form By requestin� the rebale chec's be made <br />payable to lhe vendor, I agree lo the follrnving: <br />1. I wdl not receive a rebate check direcUy from the City of Eveietl. <br />< Assigning paymenl o11he rebate lo the vendor does not exempl me from Dackwater <br />Prevenlion Device Rcbale Program requiremerls. <br />fI �uthorize the release of my rebate to ihe vendnr listed on the hack of Ihis (orm pendmg <br />� approval o( ihe�mpleted �ackwater Prevenlion Device rebate packel by lhe City of Evereit <br />Property <br />, �-- <br />- - - — - - /� - <br />Date <br />