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i _ __ <br />� <br />� <br />� Backwatpr Prevention Device Rebate Program <br />' �� Vendor Payment Option Form <br />� <br />� Project Number. ___._ (City lo Piovide) <br />Please complete both sides of the torm <br />i <br />� Propert•� Owner Section: <br />i, <br />� Property Owner Name: L.,��j'_L�� ���� __ <br />i <br />I Installation Address: __2 P�,3 `a, If���►/�� �G <br />� Cily: ��_ State: l�f A�cJ' _ . Zip:. _ _ �� � -- _ <br />�_�..�7— <br />Mailiny Address (il diIlerent): <br />Cily: _ Slate: <br />Email. Phone: ( y�_��_�� I <br />�i Total Cost lo inslall Device (Irom confracfor invoice): $�_��� � _� <br />� --- - - <br />I <br />I, the properiy owner, reyuesi (u navo the City of Everetl Backtiv2ter Prevention Device rebate check <br />; for the installalion o( lhe device at ;he abnve referencod property address 6e made payable to, and <br />sent to, the vendor specified on lhe back oi lhis (orm. By requesting the rebate che�:k be made <br />payable lo the vendor, I agree to tho following: <br />1. I v�ill nol receive a rebale check direally Irnm ihe City of Everelt. <br />2 Assigniny paymenl of lhe rebate to Ihe vendor does nol exempt me trom [3ackwater <br />Prevenlion Device Rebate Pragram requiremenls. <br />� I aulhorize the relcase of my rebale lo lhe vendor listed on the h�r.k of this form pending <br />apprnval o( Ihe wmpleled Bcckwater Prevenlion Device rebate packet by lhe Cily of Everetl <br />-- I\�\\=i�C�'� � --- <br />� -i/ 1� <br />� iE i <br />Signature oi Property Owner Da e <br />