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�^��'�"" Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projecl Number. (City fo Provide) <br /> Please complete both sides of the form <br /> Froperty Jwner Section: <br /> Property Ovmer Name:��T�l� � lk � _ <br /> Installation Address: �,1 b W � M A�..�-�/� <br /> City:����'� Slate:��Zip:��2-O I <br /> Mailing Address (il dilferenf): <br /> City: Stale: 2ip: <br /> Email: `�n� ��,FhQ.-���,-t.��(�i{.,,��Phone: (�'t$j 2�9 —�� <br /> / <br /> Total Cosl to Inslall Device ((rom confractorinvoice): 5 ��•✓ <br /> I, the propeAy owner, request to have the City of Everett Backwaler Prevenlion Device rebate check <br /> for the inslallation of the device at the above referenced property address be'made payable to, and <br /> senl lo,the vendor,pecified on lhe back of Uiis form. By requesting the rebale check be made <br /> payable lo lhe vendor, t agree lo the following: <br /> 1. I will not receive a.rebate check directly from lhe Cily of Everell. <br /> 2. Assigning payment of ihe rebate lo the vendor does not exempt me (rom Backwaler <br /> Prevention Device Reb�te Program requiremenls. <br /> I authorize the release of my rebate to the vendor listed on the back of Ihis form pending <br /> approvai ol lhe compleled Backwater Prevenlion Device rebale packet by the City of Everelt <br /> � � _�o `' <br /> ature of Prop y Owner Date <br />