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Backwater Prevention Device Rebate Program <br /> Vendor Payment O�tion Form <br /> Froject Number. (Cityto Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Properly Owner Name:�:.X�I� � �-+��� <br /> Installation Address: a ��� ��'F��'�_ �(� <br /> City:���G� Stale:�-�Zip: ��Q p � <br /> Mai!ing Address (if diNerenQ: <br /> Cily Stale: Zip: <br /> Email��c�;L'c_���(ci ��+�iJ.�L� Phone (4.�1�' ��"51 <br /> Total Cost to install Device (irom contractorinvoice): $�¢�� . Q?2 <br /> I, the property owner, request to have the Cily of Everett Backwater Prevention.Device rebale check <br /> for ihe installation of the device at the above referenced property address be made payable lo, and <br /> sent to, the vendor specified on ihe back o(this form. By requesting the rebate check be made <br /> payable to lhe vendor, I agree lo the following: <br /> 1. I wiii not receive a rebalr. check direcUy from the City of Everett. <br /> 2. Assignmg payment of the rebate to the vendor does not exempt me from Back�vater <br /> Prevention Device Rehate Program requirements. <br /> I authorize the release of my rebate to the vendor listed on lhe back of lhis form pending <br /> approval of U�e compieted Backwater Prevention Device rebale packel by the City of Everett <br /> ' ,�� � ,? lS <br /> Signalure of Property Owner Dale <br />