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��%�� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Praject Number: ___. __ _ (Ciry fo Provide) <br />Please complete both sides of the form <br />Propery Owner Section: <br />Property Owner Nan <br />Installalion Addr�ss .7 � ) ����J�A/l �'1 / lCrl_`Yi _ <br />City: v`�� i_ Slate: u� J7 _ Zip:__����� <br />-�--� _ � � '/ <br />tvtailin;; Address (il diffe nQ: _�r��jL �, �.. � Q 7 <br />/ � <br />c�cY: '�c s��i� �f%z�P: 9'�'�3-70 <br />.` <br />Email:/Y/L 2 C c�'� ,��� _ Phcne: 1���.3Q -q��_ <br />Tolal Cost to Install Uevice (/rom confractor invoice): S <br />I, the property owner, request lo have the City of Everelt Bacf.waler Prevention Device rebate check <br />for Ihe inslallaUon o( lhe device at the above referenced property address be made payable to, and <br />sent to, lhe vendor speci5ed on the back o( this form. By requesling lhe rebate check be made <br />payable to lhe vendor, I agree to the (ollowing: <br />1. i v�ill not receive a rebate check directly (rom the City of Everett. <br />2. Assiyning paymenl ot lhe rebate to lhe vendor Aoes not exer �pt me tiom Backwater <br />Prevention Device Rebalc Program reGuirements. <br />Ii authorize the release o( my rebalc lo lhe vendor lisled on the back oi this form pending <br />approval of Ihe completed Backwaler Prevenlion Device rebate packet by �he City of Everett <br />Signature of Property Owner <br />Date <br />