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Backw�#er Preventi��n Devic� <br />Rebate Program <br />For internal Usc: Project Number: <br />Ven�lor Payment Option Form <br />Please complete both sides of the form <br />Property Owner Section (please print): <br />Properly Addre� <br />+-�Y���OIL .City� sta�n�in�^,�ZiP <br />Altcrn t M ilin Ad rP s City <br />--�-.���_`4�-�C.- <br />f'�,one - r_mai� <br />� <br />I, the Property Owner, requesl to have the Cily of Fverett F3ackwater Prevention Device <br />reb�te r,heck tor the ins!allation reterencsd al thF Property A�ldress be made payable <br />lo, and sent lo, the Ven�lor. By requesting lhe incentive/rebale check be made payable <br />lo the Vendor, I ayree to !he following: <br />1. I �vill not receive a Rackwater Prevention Device rot�ate cher.k directly trom lhe <br />Cily of Everelt. <br />2. Assigning payment of ihe Oackvrater Prevention Device rebale to the Vendor <br />dnes no4 exempt me from B��ck�vate: Prevnniion Device Rebate Program <br />requirements. <br />I�iulhorizc the release of my rebale to lhe Vendnr listad c!i page Iwo o( this (orm <br />pending approval of thc� r.ompleted fi,�ckwaler Prevention Device rebate package by <br />the City cf Gverett <br />�; ,'�i�/I'�. 1 �7 �-�-- <br />S��jalure of Pmperty O�tiner <br />U <br />Revised 9/3/7.014 <br />_=I-2����? - <br />Date <br />Par�e 1 of 2 <br />