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Backwater Prevention Device Rebate Program <br /> � Vendor Payment Option Form <br /> i <br /> Project Number. _ (City to Provide) <br /> Please complete both sides of the form <br /> Property Own.r Section: <br /> Property0wnerName: 3�+ ��'f4�f� S✓ __— <br /> Installation Address: I b v q i ✓✓�nr 'ns� V�Y-� Q' <br /> �'; City: ��q rs't"� Slale: -✓H Zip. °i 4?J l <br /> ! ��ailingAddress(i/dif/erenfJ: P� Q�� 6 �7 — <br /> I City: L Jt rt-NS" State: .�I� Zip: `t�2 0 ( <br /> Email: S�aits�.l� K c�m� .�.r� . rt e� Phone:(k�s) a�Z -51 v � <br /> ' Total Cost lo Install Devlce (from contracforinvoice): S .Z`l8 H. 3 C <br /> I, the properly owner, request to have the City of Everett Backwaler Prevention Device rebate check <br /> for the installatinn of the device at lhe above referenced property address be made payable to, and <br /> sent to, the venoor specified on the back of this form. By requesling the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will not receive a re6ate check directly from the Cily of Everett. <br /> 2. Assigning pa;-ment of the rebate to the vendor does not exempt me from B.:ckwater . <br /> Prevenlion Device Rebate Program requirements. � <br /> I authorize Ihe rclease ot my rebale to the vendor listed on the back of ihis form pending <br /> approval of the completed 3ackwater Prevention Device rebate packet by the Ciry of Everett <br /> yaH l� .Q.�''"`t � (� 6� fs <br /> Signature of PropeRy Owner Date <br /> I <br />