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Backwater Prevention Device Rebate Program <br /> Vendor Payment Qption Form <br /> Pre;ecl IJumber ___ _ (Cily to P�ov�de) <br /> rleasa coi�ipieCe aoiii sides of fiie 4�rrn <br /> Property Owner Section: <br /> �----- --- — --- -� --- <br /> IProperty O�vner Name: �1_Z ��-j e=}'h_ 1�a t-Y� P�'� � ��� �� Ct <br /> ' I Installation Address. l `� V 2 �� u��E.3.�--\\ e-r V e __ <br /> iCity' ��e,�^�f� _ State �� � 2ip: � �s Zu � _ <br /> ! fviailing Add�ess (iI diHarent) <br /> iCity: Slate: _ Zip: _ <br /> ; Email Phone: (Zo(�,_7� g- -�j �?3 <br /> � Total Cost to Install Device (Irorn contrac(or invoice): 5 <br /> -- ---- - <br /> I, the property owner, request to have the Crty o( Everett Backwater Prevention Dewce rebate chec <br /> tor the mstallaUon of Ihe device at the above referenced property address be made payabie lo, an� <br /> sent to, the vendor specified on Ihe back oi this (orm Dy requesting ihe rebate check be made <br /> payable to the vendor, I agree to the following: <br /> t I ia�ill not rer,eive a rebate check directly from the Ciry of Eveietl <br /> 2. Assigning payment o(lhe rebate lo Ihe vendor does not exernpl me (rom �ackwater <br /> �revention Device Rebale Program requirements <br /> I authorize the release of my rebate to Ihe vendor listed on the back of Ihis (orm pending <br /> approval ef lhe completed Backwater Prevention Device rebale packet by lhe City of Everetl <br /> I �4..,��� r��J� _ 2 - � _� 5� - <br /> Signature of Property Owner Date <br /> �-- - ��r-1� w� �k�-+� — — - <br />