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;^��� gackwater Prevention Device Rebate Program <br />� Vendor Pa;�ment Option Form <br />Projecl Number. (City to Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />property Owner Name: -.� Ll Y L��- ' <br />Installalion Address: � � � � � � � <br />City: � �ei �� Stale: �/1� [^-r Zip: � � �CJ � <br />I r�� �liee.v pr , <br />Mailing Address (i(diHerent): 3 �-� � � <br />Ciry: �--�' �^`I� � y __ State: �_ Zip: � � 2-�'� <br />EmaiP. S h�Q`'`�I �W n-"v,'e��-,Con'' phone: (�"'I 73a-z3�9 <br />Total Cosl lo Install Device (from contracfor invoice): $ 2 1� �1 �'�� <br />I, the property owner, requesl to�have the City of Everett Packwater Prevention Device rebate check <br />for the installation of lhe device at lhe above referenced property address be made payable lo, and <br />sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br />payable to lhe vendor, I agree to the following: <br />1. I will not receive a rebate check direcUy from the City of Everett. <br />2. Assigning paymenl of the rebate to the vendor does nol exempl me from Backwater <br />Prevention Device Rebate Program requirements. <br />I authorize the release o( my rebate to Ihe vendor listed on the back of this form pending <br />approval�of lhe completed Backwater Prevention Device rebale packel by the Ciry of Everell <br />/l /� 2v ly <br />Signalure of Property 0 er Date <br />