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��/�' Backwater Prevention Device Rebate Program <br /> �M�7T Vendor Payment Option Form <br /> Project Number. (Ciry to Provide) <br /> ?iease co��ipieie bo4i: sides oi Yi�e iorrn <br /> Property Owner Section: <br /> Prepe�iy Ov.�ner Name: _��QISQ,� � <br /> InscallationAddress:��l�S_�{� ,��,� ��,,711F <br /> i C <br /> Ciiy:.1–��Q."��' State: L/�A Zip_ 9�2� l <br /> Mailing Address (if diNe�ent):_��yn� � �_��� � <br /> City: State: Zip: <br /> Email: _ r��, >�41.�0�� �}�, -� ��(lj'+1 Phone: (NLS")IZZ-Z7_Y�_ - <br /> Total Cost to Install Device(fiom contrac(or invoice):5�.SQQ <br /> I, the property owner, request ln have lhe City of Everett Backwaler Prevention Device rebate chec's <br /> for Ihe Installation of Ihe device at the above referenced property address be made payable to, and <br /> sent to,the v�:ndor specified on the back oF this form. By requesting the rehale cher,k be made <br /> payable to tl�e vendor, I agree to ti;e follo�viny: <br /> 1. I �:�III not receive a rebate check direclly from the City of Fverett. <br /> 2 Assigninc� payment o(the rehale lo the vendor does nol exempt me from Backwater <br /> Prevention Oevice Reba�e Program requirements <br /> I authorize the reiease of my rebate to the vendor listed on the back of this form pending <br /> ❑pproval ol thc r,ompleted (3ar.kwater Prevention Device rebate packet by lhe City o([veretl <br /> ___��f'�- - - -U I ��/S <br /> Signature of Property O�vner Date <br />