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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Pro�ecl Number _ _ _ _ ___ (City to Prc�vide) <br />Please complete both sides of the form <br />Property Owner Section: <br />' ��. C''p�c.c <br />Property O�vner Name: � {LlCt t4-til _ <br />i <br />InslaltationAddress:_ 9!9 7�'aN-� UE"• <br />City: __ '�---1) E k' �� T T State: _ CJA Zip 9� �D � <br />' �vtailing Address (il d�flerent): � f�,rc <br />City: _ <br />Email: <br />State <br />Phone ( )_ <br />Tolal Cost to Install Device (Irom confractor invoice): 5_p'�4-+�1�� <br />I, the property owner, request ro have the Gty of [verell Backtivaler Prevention Device rebate check <br />for the mslallation of the dewce at the above re(erenced property address be made payable to, and <br />sent lo, lhe vendor specifled on the back of this form By requesling the rebate chec4 bt. m�de <br />payable to the vendor. I agree lo the follnvnng. <br />1 I�vill not receive a rebate check directly Irom the City of Everelt <br />2 Assigning paymenl of ihc rebate to the vendor does not rxernpt me Gom Back�vater <br />PravenUon Devlcr. Rebate Program reqwrements. <br />� I authon�e lhe reicasc ol my rohate to tho vendor listed on the back nf this (orm pendiny <br />Iapproval of Ihe compieled Back�vater Prevenlion Device rebate packel by lhe City of Everett <br />' /�Lr�C�;.� U°,.�,���--- - <br />-� <br />Signature of Property Owner <br />�r /� <br />Datc <br />