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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form � <br /> Project Number:_ (City to Provfde) <br /> ' Please complete both sides of the form <br /> Property Owner Section: <br /> Properly Owner Name: � /t � L' � � �r — <br /> Installation Address:�'�S � � / �� J� <br /> City:�/P�'r�� State: !�� Zip: � ����! <br /> Mailing Address(if diflerent): �S�/� .���/�`�?�' �p-� <br /> City: L^N�7✓1!� State:�Zip: ����7 <br /> ✓ (l <br /> Email: �-�a �P / ��`�MP/� �'� r oe�Cn�n Phone: (yzs} S(o�/ -z96 � <br /> Total Cost to Install Device (lrom contractor invoice): $ a� ,7r�•�S , <br /> I,the property owner, requesl to have the Cily of Everelt Backwater Prevention Device rebale chedc <br /> for the installation oi lhe device at the above referenced praperty address be�made payable.to, and <br /> sent to, the vendor specified on the back oi this form. By requesting the rebate check be made <br /> payabie to the vendor, I agree to lhe following: <br /> 1. I will not receive a rebate check di2ctly(rom the City of Everett. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements. <br /> I authorize lfie release of my rebate to the vendor listed on the back of this form pending <br /> approval of the completed Backwater Prevention Device rebate padcet by the City of Everett <br /> t— <br /> � . // �//7 <br /> ignature of Property Owner Date <br />