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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Number. (City to Provide) <br /> Please complete both sides of the form <br /> ' Propert"y Owner Section: <br /> Property Owner Name: ��p.(� L��r a r� � <br /> Installation Address: � �� �Clf�O� }j31�-' <br /> City: J<m (� .� _State� �l l Zip' l�aC� <br /> Mailing Address (d dillerent): � 1'� 1 �1f' <br /> C�ty: �C����P..�V State:j��Zip: �C�J-S � <br /> --- ___ __ _ ... _ - - — _ -_- -.. _ - — <br /> Email: Phone ( j <br /> Total Cost to Install Device (lrom contractor invoice): S f��C� � <br /> I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for lhe installalion of lhe device at the above referenced property address be made payable to, and <br /> sent to, the vendor specified on the back ot this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the tollowing: <br /> t. I will not rece�vc a rebale check directly from the City of Everett. <br /> 2. Assigning payment of Ihe rebate lo the vendor does not exempt me from �ackwater <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my rebale to the vendor lisled on lhe back ot this form pending <br /> approval of the comple[ed Backwater Prevention Device rebate packet by the City of Everett <br /> (� � ` <br /> J / ,� �GC�i % ��•,v ; ��� ,o <br /> Signalure of Property O�vner �u�j� Date i <br /> � <br />