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�� Backwater Prevec�tion Device Rebate Program � <br /> F�� Vendor Payment Option �orm <br /> Project Number. (City to P�ovide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> �_-- �. <br /> Properly Owner Name: �_�pf,q_.�1 e S� ____ <br /> Installation Address: J Q � � �—�0\) � _�__ <br /> City-� �� `�� Slate: v�Zip: I gZ 0 � <br /> Mailing Address (iI dif(erenfJ: <br /> City: State: Zip: <br /> Emaii: Phone: ( ) <br /> Total Cost to Inslall D2vice ((rom contracforinvoice): $ <br /> I, lhe property ovdner, request to have Ihe City of Everett Dackwater Prevenlion Device rebate check <br /> for the installalion of the device at lhe abo•de re(erenced propeAy address be made payable Iq and <br /> sent lo,the vendor specified on lhe back of Ihis form. By requesting thc rebale check be made <br /> payable lo the vendor, I agree lo the following: <br /> 1. I will not receive a rebale check directly irom the City of Everelt. <br /> 2. Assigning payment of lhe rebate lo lhe vendor does nol exen�pt rne (rorn Back�•�aler <br /> Prevention Device Rebale Program requiremenls. <br /> � I authorize Ihe releasc of my rebale lo thc vendor lisled on the back of Ihis funn pendiny <br /> approval of the compleled Backwaler Prevenlion Device rebalo packel by the Cily of Fverett <br /> Ti — �/ �/1 / �-- <br /> Signalure of Properly Uwner Dal—LL£ � / <br />