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,!^%�� gackwater Prev�ntion Device �ebate Program <br /> � Vendor Paymerik Qntion Form <br /> Projer.t Number. ______ (i:ity(o Piuvide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> PropertyOwnerNeme: C/v` ` � �� � v — <br /> Installation Address: l fl�� !��� ��l <br /> City: C✓L+�� _ _Slale: GJ� Zip: 9�Z01 <br /> Mailing Address (i(diNerent): _ l!c?�_a. /S� f}'L�c N � <br /> City:�C�-�'�d� State: lnJA Zip: � $� 7� <br /> Email: .1 � i 5 ' �D✓Ylc..°us�t. /7� Phone: (ac� _,�j� 'f-670� <br /> Total Cost to Install Device (Irorr, contracforinvoice)� $ <br /> I, the property owner, requesl lo have Ihe City of Everetl Backwaler Prevention Device rebate check <br /> fnr the installalion of the device at lhe above referenced property address be made payable to, and <br /> sem lo, the vendor specified on Ihe back of this form. By requestiny Ihe rebate check be made <br /> payablr to the vendor, I agree to the following <br /> 1. I will nol receive a rebate check directly irom lhe City of Everett. <br /> Z Assigning paymeN oi the rebate tn the vendor does nol exempl me from Rackwaler <br /> Prevention Devicz Rehate Proyram reqwrements. <br /> I author2e the releasr. of my rebate lo ihe vendor lisled on the back o(Ihis (orm pending <br /> ❑pproval of the complcied Backwater Prevenlion Device rebate packet by the City of Everett <br /> i <br /> , �,r,�,�—_- � - 9-ao i� <br /> Sig�ial�re o( Property Owner Date <br /> I ✓ _ <br />