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�� Backwater Prevention Device Rebate Program <br /> Vendor Payment Opti�n Form <br /> Projecl Nurnber. (Cit}�lo Provide) <br /> Please complete both sides ot the form <br /> Property Owner Section: <br /> � -- --- <br /> Property Owner Name: __ E✓4� J GA,�RETT _ __ <br /> ' Installation Address. ?SO� �dCKE4 /QvE, <br /> Cdy: -- E�/�QC;T Sta�e VVA. _Zip' --c1�LD I <br /> ' Ivlailing Address (i(di�Nerent) <br /> City -- -- - -- -- Slate: --- —Zip. <br /> Email: 8�arrett yZC�comrArF. nef Ph�ne: (� 339-zzar <br /> Tctal Cosl to Install Device (from contnc[or invoice): 5_4,Se�/ _ <br /> �_ -- -- -- — -- -- _— -- — <br /> I, the property o�a�ner, request to have ihe City of Everr.lt Back�a�aler Prevention Device re6ate check <br /> (or the installalion oi the device at the above referenced property address be made payabie to, and <br /> sent lo, Ihe vendor specif�ed on Rie back of lhis fonn 6y reyuesting the rehate check be made <br /> payable to the vendor, I agree lo the following: <br /> t I wiil not receive a rebate check directiy from the City o( Everett <br /> 2 Assigniny payment nf the rebale lo the vendor does nut exernpt ine liom E3ack�t•ater <br /> Prevenlion Device Rebate Program reyuiremenls <br /> I authorize lhe release of my rebale to tfte vendor listed on the back o(lhis fonn pmidiny <br /> approv:,t of Ihe complel?d Bar.kwaler Prevention Device rebale packel by Qie City of Everett <br /> �� � �� <br /> I <br /> � �ti�.,_ ���tix.v�-C��-- _ 3-1_s-- i� � <br /> II Signalure of Property Owner Dale <br /> I — - -- ---- ------ - — -- -- -J <br />