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Backwater Prevention Device Fteb�te Pr�gram <br />�� Vendor Payment Option t=orm <br />Project Number. (City to Provitle) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: _ V✓�(.W'I C.✓I n P ���CS <br />Installation Address: ��� '��1 }— �� <br />c�ry: �✓-��Ct-' Stale: I/U F�"� _ Zip: CI d�-� b I <br />Mailing Address (i( dilferenfJ: <br />City: <br />State: <br />Zip: <br />Email: �`vhe�-f-s 3�3�r.�cc_i ( • C�v�-, Phone: (�;�2/0 —�'S��-- <br />Total Cosl to Inslall Device (lrom contractorinvoice): $ p,�s�. � <br />I, the property owner, request to have lhe City ot Everetl Backwater Prevention Device rebale check <br />for lhe inslallation 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 rebate check be made <br />payable to the vendor, I agree lo the (olluwinc: <br />1. I will not receive a rebale check directly from the Cily o( Everelt. <br />2. Assigning payment of Ihe rebate lo the vendor does not exempt me irom Backwaler <br />Prevention Device Rebale Program requiremenls. <br />I authorize the release of my rebale to the vendor listed on the back of Ihis form pending <br />approval of ihe completed Backwater Prevention Device rebate packet by the City of Everetl <br />�z,�.�.�n_.�,�.�-e�� <br />Signature of Property Owner <br /></�— 3 �— /5— <br />Date <br />