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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Number: _ (City to ProviJe) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name� ���'I� '"�V4r�.�1 �PJ <br />Installation Address: 22b�% l./k� Q Y1d�l'lG� '\�1�- . _ <br />GV�Q,,I/� State' w/� Zip ��20 I <br />City: _.� <br />Mailing Address (rl diHerent): <br />City: <br />State: <br />Email:[1C,rnPJVYLUrC�LP�Ii CDVT�C.G(�1 •V1C.1 Phone: (� '-t�1-a`t'�� <br />--- `-o <br />Total Cost tu Install Device (lrom confracror invoice)� $ ��C�C7 <br />I, the property owner, requesl to have the City of Evereri Backwater Prevention Device rebate check <br />for lne inslallation o( lhe device at lhe above relerenced property address be madc payable lo, and <br />sent to, the vendor specified on the back of thls form. By requesting the rebate check be made <br />payable to Ihe vendor, I agree to the following: <br />1. I will not receive a rebale check directty from lhe Cdy o( Everelt. <br />2. Assigning payment o( the rebale to Ihe vendor does not exempt me (rom Backwater <br />Prevention Dcvice Rebate Program requiremenls. <br />I aulhorize the release ot my rebatc to the vendor lisled on the back of lhis form pending <br />approval of lhe compleled Backwater PrevenUon Device rebate packel by Ihe Cily of Everett <br />_�L'aLY�-i!d <br />Signature of Property Owner <br />5�2�I►5 <br />Date <br />