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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: (Cify to Provide) <br />Please•cornplete both sides of the form <br />Property Owner Seckion: <br />Property Owner Name: SP� N� K��L��� <br />InstailationAddress: 22-01 ��n��.� ��� <br />City: �CJ✓ ��� State: <br />Mailing Address (if dillerent): <br />City: <br />Email: <br />State: <br />Totai Cost to Ins1aIl.Device (lrom confractorinvoice): $ <br />Zip: -` OZC7� <br />Zip: <br />Phone:( )_ <br />�y�,O� <br />I, the property owner, request to have the City of Everett 8ackwater Prevention Device rebale check <br />for Ihe instailation of the device at the above referenced property address be made payable to, and <br />sent to, the vendor specified on the back of this form. By requesfing the rebate check be made <br />payable to the vendor, I agree to the following: <br />1. I will not receive a rebale check directly from.the City of Everett. <br />2. Ass�gning payment of the rebate to the vendor does not exempt me from Backwater <br />Prevenlion Device Rebale Program requirements. <br />I authorize the release of my rebale to the vendor listed on Ihe back of Ihis form pending <br />approval of lhe completed Backwater Prevenlion Device rebate packet by the City of Everett <br />� lJ-�- � C <br />Signature of Property Owner <br />2�- l� <br />Dale <br />