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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number. (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> � Property Owner Name: ��Q�'"� ��`h /� r Lu�u �+ <br /> Installa6onAddress: J�� D�kS <br /> Cily: �GvG - State: �/ ' _ Zip:_ `g20 I <br /> Mailing Address (i/diHerenf): �,�06 2 3d ������G-� <br /> City: ('V��+:'�c �A'r� Slate: N� Zip: g� Z S�Z <br /> Email: T��--!'/�'leti�ala�fhar'� Cdn" _Phone� (Y1S) Ytg�Z-Y`�_ <br /> Tolal Cost to Inslall Device ((rom contractorinvoice): 5 �y�7 <br /> �, 9i <br /> I, the property owner, request lo have ihe City of Eve:etl Backwater Prevenlion Device rebate check <br /> for the installation of the device at the above referenced property address be made payable ro, and <br /> sent to, lhe vendor specdied on the back of lhls form. By requesting thc rebate check be made <br /> payable to the vendor, I agree to lhe follo�ving� <br /> 1. I wiil nol receive a rebale check direclly from the City of Everett. <br /> 2. Assigning payment o(the rebat�to lhe vendor does not erempl me from Backwater <br /> Prevention Device Rebale Program requirements. <br /> I authonze Ihe release of my rebate to the vendor listed on the back of this form pending <br /> approval o(lhe completed Back�valer Prevention Device rebate packet by lhe City ot Everelt <br /> if,/".�l �Z8 / 7 <br /> Signature of Property Owner Date <br />