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� Backwater Prevention DEvice Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Number. (City(o Provide) <br /> Please complete•both sides of the form <br /> Property Owner Section: <br /> PropertyOwnerName:GH/�5 /�i�F.�� � <br /> � <br /> Insta�la�ion Address: �/33/ feii�,�e D�Z <br /> City: .�yP/G/�a' State� w/Y Zip: <br /> Mailing Address(if diNerent): <br /> City: �iaw/,�/>>�� State: w/� Zip: Ta`� <br /> Email: Phone: ( ) <br /> Total Cost lo Install Device (/rom contractor invorce): S .Z..v�.' I <br /> I, the propeAy owner, request lo have the Cily of Everett Backwater P.revention Device rebate check <br /> for lhe inslallalion of the device al the above referenced property address be made payable to, and <br /> seM to, the vendor speci(ied on the back o(this form. By requesting the rebale check be made <br /> payable to lhe vendor, I agrec todhe follo�sing: <br /> 1 I will not receive a rebale check directly fran Ihe City of Evere�t. <br /> 2. Assigning paymenl o(the rebate�o Ihe vendor does not exempt me from Backwaler <br /> Prevenlion Device Rebale Program requiromenls. <br /> i authorizc Ihe relr.ase of my rebate to ihe vendor lisled on the back of this form -snding <br /> approval of Ihe compleled Backwater Prevenlion Device ret�ale packet by the City of Everett <br /> � �_ <br /> Signature o(Property Owner Dale <br />