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� Backv►�ater Pre4�ention De�ice Rebate Program <br /> Vens�or Payment Option Form <br /> Project Number. (Qlty to Provide) <br /> Piease complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name:��/ ���'�i� <br /> InstallationAddress� � � 1�1.C.� <br /> c�ry: �V Y State: W� zip: ��o�O,f � <br /> Mailing Address(!t di8erent): <br /> City: Si�ie> rip: <br /> Emaii; Phone:( ) <br /> TOFa)Cost to Install Devir,e(/rom contiactor Involce):$ <br /> I,the property owner,request tn have:the Cify of Everett Backwate;PrevenNon Dev.ice rebate check <br /> for the.instellation of the device at the above referenced property address be made payable to,end <br /> sant to,the vendor speo�ed on the back of this form. By requestir�g fhe rebate cfieck 6e made <br /> payat!e ro ltie vendor; I agree to tAe following:. <br /> 1. f wlll naCreceive a rebale pheck directlgfrom the City of Everett: <br /> 2. Assigning payment of the repate fo the vendor does noE exem�me irom Backwater <br /> PrevenHon Device Rebate Program requirementa <br /> I authorize the release of my rebate to tFte verrdor fls(ed on flte back oi this form peDdirlg <br /> approval of the completed Backv�taier Preventlon Device rebate packel by the Ciry of.Eve2tt <br /> -l�'I �u%�r_ ia- � <br /> Signature.of Property Owner �ate <br />