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I <br /> l <br /> ( <br /> � Backwater Prevention Device Rebate Program i <br /> Vendor Payment Option Form ; <br /> � <br /> Project Number. (City fo ProvrdeJ � <br /> � <br /> Please complete both sides of the form i <br /> 1 <br /> Property Owner Section: � <br /> i <br /> p y �5��-1�►.�._�� �N� t��- -_ - <br /> I <br /> Pro ert Owncr Name: � <br /> Installation Address: �Li�_�_ � I � <br /> � �� . <br /> City: State: � Zip: I j <br /> ✓' -. � �i f <br /> Mailing Address (il dillerentJ: i j <br /> 1 � '' � I <br /> City: � ' State: �_Zip: � <br /> i <br /> Email: i Go��tt�,G��� -�Phone: ( ����� i i <br /> Tolal Cost to Install Device (Irom cont2cronnvoice): 5 /� � �� � <br /> I I � <br /> I, the property owner, requesl to have the City of EverElt Backwater Pre��ention Device rebate check ! <br /> for the installalion of lhe device at Ihe above referenced property address be made payable lo, and � <br /> senl to, the venCor speclfied on the back ot this form. By requesting the r=bate check be made � <br /> payable to the vendor, I agree to the following � <br /> i <br /> 1, I will not receive a rebate check direclly from�he City af f_ve�etL } <br /> 2 Assi�niny payment of Ihe rebate to fhe vendor does not exempt me from Dackwaler <br /> Prevenlion Device Rebate Program requirements. . <br /> ---- -- - � <br /> I aulhorizc the release ot my rehate lo the vendor lisled on Ihe back of lhis fonn pendiny � <br /> approval o(the compleled Backwa�er Prevenlion Device rebate packet by the City ol Everelt � <br /> � � C ' � ,2 8 r � <br /> , <br /> Signalur of Property Owner Date j <br /> — -- — --- i <br /> � <br /> i <br /> i <br />