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� . '�. '•' �h:;.� `':`:�t�` <br /> ��?r'`�=�� �.�„ <br /> � . <br /> iBackwate�'Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> ; <br /> � Project Number. (City�o Provide) <br /> I • <br /> ; Please complete both sides of the form <br /> I <br /> IProperty Owner Section: � <br /> I <br /> � PropertyOwnerName: �7r�V� �R�(1/�/� <br /> i q �� � <br /> i InstallationAddress II.,2�I l�lGLb��- � <br /> ! city:�,�,-�_�state:�Zip: 9�,LD'l _ _ _ <br /> � Mailing Address (if diNerent): �i 3/� ��-S `_- �� s <br /> I City:�UEVa�_ Stale:�_.Z p:_�.,L6 d <br /> � email:� vuar7.,17� Gthna.;I. /�avv, _ Phone: (!F�' �3� 9'�,� <br /> iTotal Cost to Install Device (from confracforinvoice): $ <br /> � <br /> � <br /> � I,the property owner, request to have the City of Everett Backwater Preveniion Device rebate r,heck <br /> for the installalion of the device at Ihe above referenced property address be made payable to, and <br /> sent to, Ihe vendor specified on the back of this form. By requesting lhe rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will nol receive a rebate check direcUy from the City oF Everett. <br /> 2. Assigni�g payment oi the rebale lo ihe vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requiremenls. <br /> i i <br /> ! I authorizc Ihe release of my rebale lo Ihe vendor;isted on ihe back of this form pending i <br /> � approvai of the completed Backwater Prevention Device rebate packet by the City ot Everett <br /> I <br /> � <br /> I ' <br /> I. <br />, � �� .� � l 1 / I <br /> � Signature of Property Owner Date <br /> i <br /> I <br /> i <br /> i <br /> i <br /> i <br />