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i <br /> � <br /> Backwater Prevention Device Rebate Program i <br /> Vendor P:,yment Option Form � <br /> i <br /> Project Number. (City to Provtde) : <br /> i <br /> I <br /> Please complete both sides of the fortn i <br /> Property Owner Section: � <br /> � I <br /> Property O�mer Name:.�iL1,��, � i <br /> Insfa�lation Address: � �U�D � D I { �l.0 l r � - i <br /> City.`.I)�a A��/�/I� Sfate:�Zip: �g� 9� ( � <br /> Pdliling Address(ifdi(ferenQ: � <br /> � <br /> C,j(yr State: Zip: i <br /> ( / i <br /> Email: �^ „ � .�•�,�� n ! ,i , (,�tn Phone:("[�5) � <br /> " I °� (� 5� - �. �i <br /> � <br /> Tofal Cost to InsFall�evice(from conhactor invofce):$ I <br /> t,the property owner,request to have the Ciry of Everett Backwater Prevention Device rebate check �I <br /> for the Insfallation of the device at the abave referenced proparty eddress be made payable lo, and i <br /> sent to,tho vendor spedfied on Me beck of thls tortn.By requestlng ihe iabate check be made � <br /> payeble to the vendor, I agree to the following: ` <br /> 1. 1 w;ll not receive a rebete�heck direc'dy from ihe Ciry of Everett. � <br /> � <br /> 2. Assigning peyment of Ihe rebate to the vendor does not exempt me from Backwater � <br /> Prevention Device Rebale Program requirements. � <br /> i <br /> I <br /> i authorize ihe r�lease of my rebate to ihe vendor Iisled on the back of this fortn pending � <br /> approval oF iho completed Backwaler Prevention Device rebate padcet by the City of Everett � <br /> I <br /> I <br /> i <br /> � � 1 �/ � <br /> _� � <br /> Signah,.e of Property Owner Date : <br /> � <br /> _ i <br /> i <br /> ' <br />