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/,,�' Backwater Prevention Device Rebate Program <br /> ��� Vendor Payment Option Form <br /> � <br /> � <br /> Project Number. (City to ProvideJ <br /> - Please complete both sides of the form <br /> Property Owner Section: <br /> Property O�vner Name: � r! Y..f �(2/'�� ��� ' �� <br /> Installalion Address�•� l,i C' �n .�UP <br /> City: ��i I�1�L�� State: �'f=J _Zip:���� � --_— <br /> Mailing Address(il diI(erenf): �.97lL� ' <br /> Ci�y: Slate� _ Zip� <br /> Email:�� -�f/��fGI�S� C0�9 Phone� (�i�iZ,Sf /�'�� /�' ��]_ <br /> /�,��. 3 0 <br /> Total Cost to Install.De�ice(Irom contracrorinvoiceJ: 3 <br /> I, the property owner, request to have the City ol Everett Backwater Prevention Device rebale check <br /> for the installation of lhe device at the above referenced•property address be made payable to, and <br /> senl lo, lhe vendor specitied on Ihe back of lhis form. By requesling.the rebate check be made <br /> payabie to the vendor, I agree to the foilowing: <br /> 1. I will nol receive a rebate check directly from lhe City of Everetl. <br /> 2. Assigning paymenl of lhe rebale lo Ihc vendor does nol exempl me from Backwater <br /> Prevenlion Device Rebate Program requiremenls. <br /> I aulhorize lhe release of nry rebatc to the vendor listed on the back ol Ihls lorm pending <br /> approva� o(the compleled Backwaler Prevention Device rebale pxket by Ihe City of Evcrett <br /> �y_ yr,-�� � J�_ � <br /> Signature o(Property Owner Date <br />