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Backwater Prevention Device Rebate Program <br />Vendor Paymenf Option Form <br />Pm�ect Number ---- -_— ---_ -_ (Cit}� !o Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />P� �pEriy Otvner Name: � e /r � � /� 5 ��I1 �- <br />Installation Address a %// ���_1�� ✓C . <br />City x✓r r _ State: u'�w z�P:_ 9 F.� c/ _ <br />t�lailing Address (il aiHerent): <br />City: <br />State. <br />Zip: <br />Email: Phone: ��� 15� .z � /� ;7'% <br />Total Cost to Install Device ((rom contractor invoice): 5 o��p�_ <br />I, the propeily owner, request to have the City of Everell Back�valer Prevenlion Device rebate check <br />for lhe installalion of lhe device at Ihe abore re(erenced prope�ty address be made payable ;o, and <br />sent to, the vendor specified on U�e back o( Ihis form. By requesting the rebate check be made <br />payable to the vendor, I agree lo the follo�ving: <br />f <br />I <br />1. I �vill not receive a rehale check direclly from the Cdy of [veretl. <br />2 Assigninc� paymenl of the rebate to the vendor does nol exempt me from Backwaler <br />Pieven�ion Devicc Rebate Proyrain iequiremenls <br />I authorize the release of my reb�te to lhe vendor listed on Ihe back of Ihis lorm pending <br />approval of fhe completed Backwaler Preven�ion Device rebate packel by ihe Cily o� Everelt <br />f� � / <br />``�'r -;, �!•_. �' e <br />Signature o( Property Owner <br />i,/{ T Lni S _ <br />� <br />Date <br />