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Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Projecl Numbec ;City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property O:vner Name� �� 1- <br />� Installalian Adaress. >�°� <br />' C��y <br />I h4ailing Address (if diNerenf): <br />C�ty: <br />I Email: <br />/�<i..%,1���. <br />State: <br />State: <br />Total Cost to Instalt Device (Irom conVacfor invoice): 5 <br />--� <br />Zip:_ — — � <br />� <br />Zip: <br />Phone:( ) <br />I, the property owner, request to have the Cdy of Everelt Backwaler Prevention De��ice rebate check <br />for lhe inslallation o( lhe device al the above referenced property address be made payable lo, and <br />sent to, the vendor specified on the back of this form. By requesling the rebale check he made <br />payable to thc vendor, I agree to the following. <br />1. I will not receive a rebate check directly irom lhe City of Everetl. <br />2 Assigning payment of thc rebale to lhe vendor does not exempt me L•om Back�vater <br />Prevenlion Device Rebate Program requirements. <br />� <br />I aulhorize the release of my rebate to Ihe vendor listed on the back of this form pending <br />approval of the completed Backwater Prevention Device rebale packet by the City oi Everett <br />"^ /� }' L, � � <br />Signe!ure ot roperty Owner Date <br />