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� Backwater Prevention Device Rebate Pragram <br />Vendor P'ayrnent Option Furm <br />Pro�ecl Number. _ _ _ _ (Git}� fo Provide) <br />Please complete both sides of tlie form <br />Property Owner Section: <br />Proper�yO�vnerName: S�£V�� k�. � TL�1t�-yF��,� K_ �l.Jct�r��_ <br />Installation Address: Zb I �i ���� ��1��—{�—_ <br />Cdy _ EVGY�T - -- State: _LU !A -- Zip. nl � %= d ' -- -- <br />Mailing Address (if diNerent)' __ __ ___ <br />City. ___ State. <br />Email: �t^u`w� F W�DS2S_L`.�S'�41�L�- .f..�— L�'�'� Phone: (��L}, .� �I -3S(��i <br />Tolal Cost to Install Device (Irom conlracforinvoiceJ S ZSGU � ___ <br />`- - -- --- --- — <br />I Ihe property owner, request to have lhe City of Everett Back�vater Prevention Device rebate check <br />for lhe installation of the dcv�cc al the above re�erenmd propeily address be made payable to, and <br />sent to, tha vendor specified on the back of lhis form. [3y reyuestiny the rebale check be made <br />p;iyable to Ihe venoor, I agree to the followiny: <br />1. I�vill not receive a rebate check directly from the City of [verelt. <br />'� Assignin�•payment of Uie rebale lo Ihe vendor does not ezeinpl me frem �ar,kevater <br />Prevention Device Rebate Frogram requiremrnts. <br />-- - — — t <br />I �uthonze the release of my rebate to Ihe vendor hsted un Ihe back of this form pendmg , <br />approval of lhe compleled 8ackwaler Prevenlion Device rebate packet by the City o( Evereil <br />��; T��<� �� ��_ <br />SignaWre of Property Owner Dale <br />