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Backwater Prevention Device Rebate Program <br /> �, Vendor Payment Option Form <br /> Pro�ect Number. __ (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Nama�_ _��C�_�../�-�5 C_� <br /> InslallalionAddress ��Uz— L'��J�U�_ <br /> Gity: �U4��1 Slate: l�f{ __Zip: �O�f� <br /> Mailing Address (ildi(/erenf): <br /> City: State: T:p: <br /> EmaiC Phone: ( ) <br /> Tolal Cost to Inslall Device (6om conhactor invoice): � <br /> I, lhe properly owner, reyuesl to have the Cily of Everetl Backwaler Prevention Device rebale check <br /> for the installation of Ihe device at the above re(erenced propedy address be made payable to, and <br /> sent to, the vendor specified on the b� :k of this form. By requa�sting Iha rehale check be made <br /> payahlc to the vendor, I agree lo the following� <br /> 1. I will not rer.eive a rebale cher.k directl�from the City of Everet� <br /> 7 Assir�ning paymenl of Ihe rebafe to the vendor does nol exempi rr^ trom Backwatcr <br /> Prevention Device Rebale Program requirements. <br /> r— — — — --- — ---— i <br /> I authorize the relr.ase �f my rebale lo the vendor listed on the bar,k o(�his form pendi�y <br /> approval ot the compleled Backwaler Prevent�on Device rebate packet by lhe City of Everelt � <br /> - - -- - -- — S Z�?. /� <br /> Signalure nf Property Ovrner Dale <br />