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i <br /> ' Backv��ater Prevention Device <br /> � F�ebate Program ; <br /> For internal Use: Projecl Numbec . __ _ <br /> I <br /> �/endc►r Payment Option Form <br /> Piease complete both sides of the form <br /> Froperty Owner Section (pleasa print): ' <br /> — ---- ---------- -- -- <br /> � l�J,�.�����«��---- -- __ <br /> �� .�r �v <br /> I Pro�P y � er Name <br /> ; /�1 _�vGK�r z��4�i����z�.r��J,9sy �',i�'—�i _ <br /> � Propr:rty Addre�ss City � State Zip <br /> ---N��-- -- --- - - <br /> Alternate Alailiny Address City Slate Zip <br /> LPhone v,f ` Emall <br /> _ y1_s�_�s=��l� ----��� =�����������r�1 : <br /> I, the Prop�;rty O�vner, reyuest to have the City of Evcrett Sackwater Prevention Device <br /> rebate check for ihe insta�lation referenced at the Property Address be made payable <br /> to, and senl to, the Vendnr. E3y requesting the incentive/rebate check he made pa��able <br /> to the Vendor, I agree to lhe following: <br /> 1. I will not receive a Back�vater Prevention Device rebate check directly from the <br /> City of Everett. <br /> 2. Assigniny payment of the 13ack�vater Prevention Device rebate to ihe Vendor <br /> does not exempt nte from B�r,k���ater Prevention Device Rebate Program <br /> requirements. <br /> I �iulhorize thr. relr�tase of my rebale to the Vendor lis(ed on paye two of this (orm <br /> pending approval o( the r.ompleled C3ack���ater Prevenlion Device rebate par.kage by <br /> !he (:ity ot F.verett <br /> L!�L�L�'-�-t/�.-(!'��j�, /'i`"l-�_ — --- . � _ /S '/'� � <br /> Signature of Proprarty F��v�Ur D��te. <br /> Pape 1 0(2 <br /> Revised 9i3l7_01A <br />