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6ackwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Pro�ect Number. (Cily Io ProvideJ <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Ovmar Name: _j �"i 1� /<,C -..� C-�14 C �t !� <br />InstallationAddress: '��� lV���nv�1cP�� 1'��7-� <br />City• �ti`Q�.r7:�� S ale: �/�%� Zip: 9�20 1 <br />I.4ailing Addross (ildil(erenf): <br />City: _______ State: <br />Ematl <br />Total Cost to Install Device (/ram contractor invoice): S ,��� �� _ <br />Phone: ( <br />I, the property o�vner, re�uest lo have 1he City o( Everett Back�vater Prevenhon Device rebate check <br />(or !he installation oi the device at the above referenced property address be made payable lo, and <br />sent to, the vendor specified on the back oi this fcrm. By requesting the rebate check be made <br />payable to the vendor, I agree to lhe (ollowing: <br />1 I will not recelve a rebate check direclly from the City of Everett <br />2 Assigning paymenl o( the rebale to the vendor does not exempl me froni BacKwater <br />Pre.vention Device Rebate Program requirements. <br />I authon�e. the release of my rebale to Ihe vendor listed on Ihe back of this form pending <br />approval of the completed Backwaler Prevention Device rebale packel by the City of Everett <br />% �— <br />/ ,�(��� �G �'c� zt� � q 2 I = <br />ignatur� of Property Owner Date <br />