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E�ackwater Prevention Device Rebate Program <br /> r Vendor Paymenti Option Form <br /> Projecl Number. . (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name:������� <br /> Installation Address: �___����_����( " '�— <br /> „ �,-��-� ��-- z� ��'.zD / <br /> City: .�� State. p: <br /> Mailing Address (il dilferenf) ____��� � <br /> City: State: Zip:__ _ ' <br /> Email:�dr-��__ ��� ��U�hone��-�Z'��� <br /> Total Cost to Install Device (from confractor invoice): S <br /> I, the property owner, request to have Ihe Cily of Everett Backwater Preverdion Device rebate check <br /> for lhe installalion of the device at lhe above referenced property address be made payable tc, and <br /> sent to, the vendor specrfled on the back oi lhis form By requesting the rebate check be made <br /> payable to the vendor, I agree to lhe following: <br /> 1. I will not receive a rebale check directly from the Cily of Everett. <br /> 2. Assigning payment ot lhe rebale to the vendor does not exempt me from Backv�ater <br /> Prevention Device Rebale Program requirements. <br /> I aulhorize the release of my rebate to the vendor listed on the back of this Form pending l <br /> approval of the completed Backwater Prevention Device rebate packel by the City of Everetl I <br /> . , _ � �� � ��is <br /> Signalure o( roperty Owner Date <br />