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Backwater Prevention Device Rebate Program <br />Vendor Payment Opti�n Form <br />Projecl Number. _ (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: S �J 1� O�^ � f U'� <br />InstallationAddress� �''U �S I�o�,��C'��� _ <br />City: V��f�c}'� State: v� Zip� �t�`L° � <br />Mailing Address.(if diHerenf): <br />City: _ State: <br />Email: <br />Tolal Cost to In�lall Device (lrom'contractorinvoice): S <br />Phone: ( <br />I, the properly owner, request to hav^ the City of Everett Backwater Prevention Device rebate check <br />(or the installation of the device at the ahove referenced property address be made payable to, and <br />sent to, the vendor speci(ied on Ihe back of this form. By requesting the rebale check be made <br />payable to thc vendor, I agree fo the following: <br />1. I �vill not receive a rebate check direcUy from Uie Cily of.Everelt. <br />2. Assigning payment o( the rebale lo Ihe vendor does nol exempt me from Backwater <br />Prevenlion Device Rebale,Program requirements. <br />I aulhorize lhe rclease of my rebate to lhe vendor lisled on Ihe back ot lhis (orm pending <br />approval of lhe compleled Backv+aler Prevenlion Device rebate packel by the City o( Everett <br />� / / <br />� �• /d . . o <br />1�1W ���� <br />Signature of.P operty O�vner Date <br />