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Backwater Prevention Device Rebate Program <br /> Vendor Payrnent Option �orm <br /> Project Number. (Cify fo Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ��5�p L�. �C�� <br /> 1 � <br /> Installation Address: c��I 7 �9iF,v��P— 5 <br /> City:�l/Qfe� _ State: 1N �' Zip: `1 �C)� <br /> � ! r <br /> Mailin�Address(if diKerent): �_ V �fw` <br /> � <br /> City:.__ State: Zip: <br /> EmaiL•J��i 1���_�.u�'10E�S� _,(/e.� Phone: (5�3)�} S`t't- CX�(/Q� <br /> Total Cost to install Device (from confractor invoice): $ '��/ <br /> I, the property o�mer, request to have the City of Everelt Backwater Preven!ion Device rebate check <br /> for the installation of the device at the above referenced property address be made payable to, and <br /> senl to,the v�ndor specified on lhe back ol this.form. By requesting the rebate check be made <br /> payable to the vendor, i agree to the(ollowing: <br /> 1. I will noi receive a rebate check direcqy from lhe City of Everett. <br /> 2. Assigning paymenl of the rebata to the vendor does not exempt rt:e (rom Back�valer <br /> Preven�ion Device Rebale Program requirements. <br /> I aulhorize the rolease of my rebate to the vendor listed on the back oF this form pending <br /> approval of the completed Backwater PrevenUon Device rebate packel by lhe City o( Everetl <br /> � i .�` �/ - / s <br /> Signature of roperty Owner Date <br />