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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: __ (Cify to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O�vner Narr <br />Installation Address: <br />Cily� �� � State: __�__ . Zip: �C�c� U I <br />Mailing Address (if diNerent): �� I% � IL-t✓LpC �'-�- <br />City: �i?Q,�P�, Stale:�Zip: C%OdUI <br />Email: _11q' h2�1-�_P�°��^ �J•.L��vYttJ� • `�'t' �S Phone: ('t'�� S�uO '�0��7 <br />TotahCost to Install Device (/rom contracfor invoice): 3 ay_�'�.�o <br />I, lhe property owner, request lo have the Ciry of Everetl Backwater Prevention Device rebale check <br />for the installalion of Ihe device al the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this (orm. By requesting the rebate check be made <br />payable to the vendor, I agree lo the follo�ving: <br />1. I will not receive�a rebate check directly irom the Cily of Everett. <br />2. Assigning payment ot the rebate to the vendor does �ot exempt me from Back�vater <br />Preve�tion Device Rebate Program requirements. <br />I authorize the release of my rebale to the vendor listed on Ihe back of this form pending <br />approval of the compleled Backwater Prevenlion Device rebate packet by lhe Ciry of Everett <br />�! 1`�" V > <br />Signature of Property Owner Da e <br />