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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Forrn <br /> Project Number. (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> PropertyOwnerName: ?���(neA �- ���lC[��nl���� <br /> Installation Address: ��3 IS C�A n, D A VP <br /> Gity: �VEi�ETI State: �1�1 Zip:_Qe� � <br /> Mailing Address(i(diNerent): <br /> Ciry: State: Zip' <br /> Email� Phone: (��) z�'�-- �3� S <br /> Total Cost to Install Device (lror conlracfor invoice): $ <br /> i _ <br /> I, the property owner, request to have ihe City of Everett Backer,�ter PrP•,ention Device rebate check <br /> for the installation of the device at the above referenced property address be made payable lo, and <br /> sent lo, lhe vendor specified on the back of this form. By requesting the rebale cteck be made <br /> payable to lhe vendor, i agree lo lhe following: <br /> 1. I will not receive a rebate check directly(rom lhe City of Everett. <br /> 2. Assigning payment of the rebate lo the vendor does not exempt me from Backtivater <br /> Prevention Device Rebate Program requiremenls. <br /> I authorize the release o(my rebale to the vendor listed on ihe back of this form pending <br /> approval of the com leted Backwaler Prevenlion Device rebale packet by lhe City of Everell <br /> . � � %/ �/S� <br /> Signature oi Property Owner Date <br />