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Backwater Prevention Device Rek�ate Program <br /> �, Vendor Payment Option Form <br /> Project Number. _ _ _ (City to Provide) <br /> Piease complete both sides of the form <br /> Property Owner Section: <br /> �-- - -------- -- <br /> Property Owner Name: /� P/l;i7 __�j �f hci2�/c� n <br /> InstalialionAddress: � �/.�/ �C/i''�/����-'� — - <br /> I Cily: I%Vc?✓�'�'�" State: ,�/� Zip:�u%/ � <br /> I h4ailing Nddress (i(diNerenQ: -- <br /> ; City: _ State: Zip: --- <br /> I Email: _ Phone: ( ) 2.5�, 3 Sr�7 II <br /> Total Cosl lo Inslall Device (lrom contracbr invoiceJ: $ Z S �d -_— _ I <br /> i <br /> i ' <br /> '----- -- - <br /> I, the property ovmer, requesl to have the Cily o( Everetl Back�valer Prevention Device rebate check <br /> (or the installation of ihe device at the above referenced property address be made•payable to, and <br /> sent lo, the vendor specified on the back o(this form. By requesling the rehate check be made <br /> payable to the vendor, I agree to the following: <br /> 1 I �vill not receive a rebate check direclly (rom the City of Everelt. <br /> 'l Assigning payment of Ihe rebale �o lhe vendor does not exempl me (rom Back�vater <br /> Prevenlion Device Rebate Program requiremen�s. <br /> il aulhorize the relcosc of my rebatc to the vendor listed on ihe hack of �his form pendmy I <br /> I approval of the compleled Backr�ater Prevention Device rebate packet by the Cily of Everell <br /> � <br /> ' �_� I�..}�-v...-._... _ —_ 1 �' � 1 ' ��— <br /> �—� <br /> Signature ot Property O�vner Dale <br />