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Backwater Prevention Device Rebate Program <br /> - Vendor Payment Option Form <br /> Project Number. (City lo Provide) <br /> Please complete both sides of tl�e form <br /> Property Owner Section: <br /> Property Owner Narne: � � , <br /> Installation Address: <br /> �1 � 5 J� <br /> City: 1•' �e-�2-� State: ��_Zip:�� d—ll I <br /> Mailing Address (ildillemnt): <br /> City: _ State: Zip: <br /> Email: Phone: ( ) <br /> Total Cost to Install Device (from contracfor invoice): $ <br /> I, the property owner, request to have the City ot Everett Backwaler Prevenlion Device rebate check <br /> for ihe instalialion of lhe device at the above referenced property address be made payable to, and <br /> sent lo,the vendor speci(ied on the back of this form. By reyuesting the rebate check be made <br /> payable to the vendor, I agree to lhc following: <br /> 1. I will not receive a rebale cheek direclly fiom lhe City af[verell. <br /> 2. Assiyning payment of lhc rebate to Ihe vendor does not exempt me from Backwatcr <br /> Prevenlion Device Rebate Program requiremenls. <br /> I aulhorize the release of my rebat� to Ihe vendor listed on the back ot this forrn pending <br /> approval of the completed Backwaler Prevention Device rebale packel by lhe Cily ot Evcrell <br /> ' \ �— / <br /> Signature of r perly Ow Date <br />