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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (Cit}�fo P�ovide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Ov+ner Name:�14eR�` ��F r�KU + F}7e F�H z HI-°Q� K <br /> InstallaGon�ddress: INOS G,eq�+a Av�e . <br /> City:�v�veTr _State: � A Zip: 4 8�-� 1 <br /> Mailing Address(if dif�erentJ: _ <br /> City: _ State: _Z�P� <br /> �ma�i: hF,_R��e�Ke ___ _y� -Llao •CcN Phone: (�+f251 �99 -7810 _ <br /> gv <br /> Total Cost to Install Device(from confractorinvoice)-5 3`�.�9-— - - —_ <br /> I, the property owner, request to have the Ciry of Everett Back�vater Prevention Device rebate check <br /> for the installation of the dovice at the above referenced property address be made payable to, and <br /> sent lo,ihe vendor specified on lhe back oi th(s form. By requesting lhe rebat�check be made <br /> payable to the vendor, I agree lo the following: <br /> 1. I will not receive a re6ate check direclly from lhe City of Everett. <br /> 2. Assigning payment of lhe rebate to lhe vendor does nol exempt me trom Backwaler <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my rebale lo the vendor lisled on tlie back ot this form pending <br /> approval of Ihe completed Backwater Prevention Device rehate packet by the City of[verelt <br /> � _ — (�27— IS <br /> Signature of Property Owner Date <br />