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�� � Backwater Prevention Device RebaYe Program <br />�w `�'-"" V�ndor Payment Option Form <br />Project Number. __ (City fo Provide) <br />Please :.or.iplete both sides of the fo*rt <br />Property O�nrne� Section: <br />Property O:wner Name: V� u� ��� ���_ — <br />Inslallalion Addres.: ��� ���'�'�' �`�� _ <br />City: �v �_� �%�- State: L.1(�- Zip:_�� � <br />Mailing Address (iI diKerent): <br />City: Sta;e ��p <br />Email:lti��rUv'S���CEI,N.�QS'i=VIY'�— Phone:�({,15j �- �' ��� � <br />c /, <br />Tolal Cosl to Install Device (Irom contracfor invoice): 5��'-T'�� �� g� <br />I, lhe properly owner, request lo have the City of Everett Back�.vater Prevention Device rebate check <br />for lhe installation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesting the re6ate check be made <br />payable lo lhe vendor, I agree to the (ollowing: <br />1 I will not receive a rebate check direcUy from the City o( Evereti. <br />2. Assigning paymenl o( the rebate to ihe vendor does nol exempt me from C�a^kwater <br />Prevention Device Rebate Program requirements. <br />I authorize Ihe release of my rebate to the vendor lisled on ihc back of this (orm pending <br />approval of the compleled Backwaler Prevention Device rebate packet by Ihe City of Everett <br />f'7-.�Gw _!1�-i�dl` _ S-: � ` /� <br />Signature ot Property Ovmer Date <br />