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Back�vater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Pruject NuR�ber.__ (�ity to Provida) <br /> Please :omplete both sides of the form <br /> Property Owner Section: � <br /> Property Ov:ner Name: �o Nr�i NA1J � �LD LIAh� <br /> Instzllation Address: I,30 f !I 3�i Nv y T � V F_N�!� I <br /> —� <br /> City: � �/r RE f7' Slate: �/� Zip: �8 2 U 1 <br /> Mailing Address (if diflerent): ��3uK 1 S!p z-- _ <br /> City: r`�uKILr!_"O Sfate: t.�/9 Zip: ��'�S'�7y <br /> Email: �y bG��uciN �' ��vl r �qu Phone: ('l2�� 8'7y -7L7y I <br /> Total Cost to Install Device(lrom contractorinvoice): S 2. �O b o'� <br /> I, Ihe property owner, request to have the Ciry oi Everett Bac:<water Prevention Device rebate check <br /> for the installa6on of the device at the above referenced property address be made payable fo, and <br /> sent to, lhe vendor specified on the back of lhis fortn. By requesting the rebale check be made <br /> payabte to the vendcr, I agree to the following: <br /> 1. I will not receive a rebate check direcUy from the City oF Everett. <br /> 7_. Assigning payment of the rebate to the vendor does not exempt me lrom �acfnvater <br /> Prevention Device Rebate Program requirements. <br /> I authorize Ihe release of my rebatc to the vendor listed on the back of this form pending <br /> approval of the completed Backwaler Prevention Device rebate packet b� � Ciry of Everett <br /> � <br /> /'' :�_ � <br /> ,�.�- — �- � s� <br /> S' nature of Property Owner �ate <br /> t <br /> � <br />