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����gackwater Preventi Device Rebate Program <br /> Vendo� Pay � ent Option Forrn <br /> Pio�ect humher __ {C�fy I �I Provlde) <br /> Please complete th sides o�tt�e form <br /> � <br /> Property Owner Section: I <br /> �I Prcperty O«ner Name. ��" '-� -Y '/� ^-" "� G 1-f-�1�D�..-1 t k.� <br /> Installation Address:Jv I U _t=—__ -`� ' '~� - I <br /> _ ._C��.Z. ii— s�aco z�p.�5 zc� � <br /> c�cy L � — <br /> IJ�ailing Address(d diRercnt): i I <br /> Gty'_._ SIBtc�,i Zip�� I <br /> Emall C u� �.� 1.�_�C.YYf.wZ .�j� Phone: fRi"1 a5 z �Is yti ( <br /> Total CoSt Io Install�evice Orom mnfratto.'� o�Ce) $���_d� <br /> —_— __. --I <br /> I, the property o�vner, requesl eo have the C�ly o [verett 6ack�valer Prevenlion Device�e6ate check <br /> for the inslallahon of the dovice at th^ above ref renced prnpery address be made payabfe to,and <br /> sent 10,Ihe vendor speafied on U�e batle of Ihis rm By requesling the�ehate chec!c be madc <br /> payable to Ihe vendor,I agrec to Ihe lollo�ving� <br /> t. i wJl not recewe a rebaie U�eck d�recty om the City ol Eve�ett <br /> : Assignin�payment of tl•�e rebate:o�h� �.^dor does nol eKempl me frcm Ract.a�aler <br /> Prevemion Dcv�ce Re�ate P�ugram �eq rements. <br /> I I authonte the celNase of my rcb;�ic to the vc�doi I�s�ed on the back nllhis form pnndmg I <br /> � approval of Ihe compleleA Brr.ka��ter Preven�n Dev�ce rebate packel by Ihe Qry of Evereil i <br /> _ . .� , I <br /> �� 2G: '� � <br /> �� <br /> Sign�lure af Proprny ��ner �ale , <br /> _ . . .... ..___.. .. . .. _._ j . . _ . . . <br /> i <br /> � <br />