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Backwater Prevention Device Reb�te Program <br />Vendor Payment Option Form <br />Project Number. ___ (Ciry to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O.vner Name: <br />Installation Address: <br />� n/ r <br />City: lAM.r,�l State: _L!/�_ Zip: gI� Zo / <br />Mailing Address (if diflerenf): <br />City: State: Zip: <br />EmaiC Ca.fc✓i /G� ta,�//�vr,�, n�f _Phone: (yL5) 11�Z- 6��5— <br />Total Cost to Install Device (/rom contractorinvoice): $ � S�•� <br />I, the property owner, request to have Ihe City of Everelt Backwater Prevention ^evice rebate check <br />for the inslallalion of the device al lhe above referenced property address be maue payable l�, and <br />senl to, lhe vendor specified on Ihe back of lhis form. By requesting the rebale check be made <br />payable lo the vendor, I agree to the following: <br />1. I v+ill nol receive a rebate check directly (rom lhe City of Everetl. <br />2. Assigning payment of the rebale to the vendor does not exempt me irom Backwaler <br />Preventlon Device Rebate Program requirements. <br />I authorize the release o( my rebate to the vendor listed on the back of this form pending <br />approval of the completed Backwater Prevention Device rebate packet by the City o( Everett <br />�� ` . �� � ,rd � �r`��� <br />,-- � <br />' Signature o( Property Ow�er _ <br />�9 �.� zo� = <br />Date <br />