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� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. (Ciry fo Provide) <br />Please complete both :.ides of the form <br />Property Owner Section: <br />Property O�+�ner Name: <br />Installation Address: <br />City: �E�E�'—'� State: <br />Mailing Address (i(dif(erent): <br />City: <br />State: <br />Zip:T�/ <br />Email����,�(j�2� -�rOl� �C�^� Phone: (� i,�S—I l L� <br />Total Cost lo Install Device ((rom contrector invoice): 5 <br />� <br />I, the properiy o�vner, requesl to have the City of Everett Backwaler Prevention Device rebat� check <br />for the installation of lhe device at the above referenced property address be made payable lc , and <br />senl to, the vendor specified on lhe back of this form: Bq requesting the rAbalebheck be made <br />payable lo the vendor, I agree lo the following: <br />1. I will nat receive a rebale �.heck direclly from lhe City of Everelt. <br />2. Assigning payment of lhe rebale to lhe vendor does not exempt me from Baclntiater <br />Prevention Device Rebate Program requiremenls: <br />I authorize the release of my rebate to lhe vendor listed on the back of lhis form pending <br />approval of �he compleled Bscka�aler Prevenlion Device rebate packet by Ihe Cily of Fverett <br />of Property Owner <br />I � ZZ <br />Date <br />