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Bacicwater Prevention Device Rebate Program <br />Ev Vend��r Payment Option Form <br />Projecl Number __ __ (City fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vner Name: <br />Inslallation Address: _�� L b--�c L"U��4- �"r7Y <br />City: �{r8Y'�Cl. State� w� _Zip���� <br />tvlailing Address (i(dilferent), _�_Q. ��J%S� �� ` <br />II City: �VQY'e(.v State: �/1�� ZiP: ��% <br />IEmail: __ f_ Phone: (�f [� %�7�v7J <br />ITotal Cost lo Install.Device (Irom confractorinvoice): 5 2, Sr�o r• _ _ <br />i <br />�-- ---- -- <br />I, lhe prooeriy owner, request to have the City ot Everelt Backwaler Prevention Device rebale check <br />for the installahon of the device at the above referenr,ed property address be made payable to, and <br />sent tn, the vendor specified on the back of this (orm. By requesting �he rebate check be made <br />payable to the vendor, I agree lo the following <br />1. I v�dl nol receive a rebale check direclly from the City o( Everelt. <br />2. Assigning payment of Uic rebale lo lhe vendor does not exempt me from E3ack�vaier <br />Prevenlion Device Rebale Proyram requiremenls. <br />I aulhonze Ihe release of my rebate to the vendor listed on the l�ack o( this form pending <br />approval o� the completed Backarater Prevenlion Device rehate packet by the City o( [verett <br />�_5���_��� - - -- <br />Sigr�ure of Property Owner <br />I <br />�i"""'`i���Ls <br />Date • <br />� <br />