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Bacl<water Prevention Device Reuate Program <br />d-rr llendor i�ayment Option Form <br />Project Number ____ _ (C�ry to P�ov;del <br />Please complete bolh sides of the form <br />Property Owner Sectio�i: <br />I <br />Preperty Owner Nar <br />Iestallation kddress <br />� City:��{���� <br />M1,iailing Address (il dillere��t): _.__ _ _ <br />� Ci1y: State: Zip_ ___ <br />I Email: Phone (����✓ �G��� <br />� � <br />Total Cosl lo Install Device (lrom contractor invoire): $�,��____ _ I <br />I <br />--i <br />I, the property owner, request to have the City of [verett Baciavater Prevemion Device rebale check <br />tor the installation of Ihe device at the above releienced property address be m�de payaU,e to, and <br />sent to, the vendor specified on the back ot �his form. 8y iequesliny the rebate check be made <br />payable to Ihe vendor, I agree to the following. <br />t. I �vill not receive a rebate check directly Irom Ihe City of Everett. <br />2. Assigninc� payment of the rebate to the vendor does nol exempt me Irom Backwater <br />Prevention Device Rebale Pronram icquirements <br />i aulhori�e Ihe rcicasc o( my rebate to the vendor lisied on thc back ot ihis fonn pending <br />approval of ihe compietoJ Rack�vater Prevent�on Device rebate packet by ihe City of Evcrett <br />� � � <br />II — ��'�Q�f��f�_�—� -- �—t'r—�� <br />� Signa�ure of Propeiiy Owner Date <br />I � <br />e <br />n <br />