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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number._ _ (Ciry to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name� �GVI Vl ����iSiN�•� ��aV`'�:�U � (�'t� <br /> Inslallation Address: Z �� 2 7�� C" '�� <br /> City: v�k'�{�1:� State: �� Zip:_ -1 U ZO r _ <br /> Mailing Address (i(diHerenQ: �Q'1'1'1'v <br /> City: _ Slate: Zip: -- <br /> Email� u���lVi c� bA�JCV(YIASc�1 . CoVv� Phone: (2��' ��3- 22b(P <br /> Total Cust to Install Device (Irom contractor invoice): 5 a4��. Q�C <br /> I, the properly owner, request lo have the City of Everett Backwater Prevention Device rebate check <br /> for the inslallation ot the device at the above referenced property address be made payable to, and <br /> sent to, the vendor specified on ihe back of this form. By requestiny the rebate check be made <br /> payable to lhe vendor, I agree to the following: <br /> 1. I will not receive a rebale check directty from the City of Everelt. <br /> 2. Assigning payment of ttie rebate to the vendor does not exempt mc from Backwater <br /> Prevention Device Rebate Program requiremenls. <br /> I authorize the release of my rebate to the vendor lisled on the back of this form pending <br /> approval of the completed Back�vater Prevention Device rebate packet by Ihe City of Everett <br /> � <br /> � � <br /> f'j� �,� / ' � �'��5 <br /> Signature o`/�roperty Owner Date <br /> i <br />