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' Bzckwater Prevention Device Rebate Program <br />�rr Vendor Payment Option Form <br />Project Numher: __ _ _ _ _ _ (Cdy to Frovide) <br />Please complete both sides of the form <br />Property Ovmer Section: <br />P�y Ovmer Name. /�-F�l�,�/�_ <br />` �1�, Inslallation Address: <br />j Ci�y _ / �� __ State <br />�?-- �_��--; <br />���" ���� i <br />U—!1" I <br />A4ailing Address (i(dif(crentJ: � �il/h.(�Q.._ _ <br />Cily. <br />Email: <br />Slate: <br />Phone: ( ) <br />Total Cosl to Inslall Davice ((rom conlraclorinvoice): S��je ee' �� <br />I, Ihe property owner, request to have the Cily of Everelt Backwater Prevenlion Device rebale check <br />for Ihe i�stallahon of Ihe device al Ihe above referenced property address be made payable to, and <br />senl to, the vendor specified on Ihe back of Ihis form By requesling ihe rebate check be rnade <br />payable to the vendor, I agree lo Ihe following <br />1 I will nol receive a rebate check direclly from the City of Everett. <br />2 Assigning payment of Ihe rebate to the vendor does not exemp! me trom Backv✓ater <br />Prevenlion Device Rebatc Progrom requiremenls- <br />I authorize lhe relcasc of my rebate lo lhe vendor listed on the bar.k of this form pending <br />approval of Ihe cornpleled Bachwaler Prevenlion Device rebate pa�kel by the City of Everett <br />a��-���-- ,� <br />Signature of Property Ov+ner <br />`; <br />Date <br />