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i <br /> �Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> ProJect Number. {City to ProvideJ <br /> Please complete bnth sfdes oi the fortn <br /> Proparty Ow�er Section: <br /> Propery Ovmer Name. Collecn Gamman <br /> Installation Address� 1832 Wetmore Ave <br /> Ciry� Everett Stale: W� Zip:9S201 <br /> Mading Address(iI dllferent): <br /> Cily: State: Zip: <br /> Email: cIp.98201@p.mall.com Phone: (425) 252•6319 <br /> 'I'ota{ Cost to Install Device (Irnm confrecfor invoice): S A <br /> I, the property owner, request to have the City of Everett Backw2ter Prevention Device rebate check <br /> for the installation ol the device at the above referenced property atldress be made payable to, and <br /> sent to,t�e vendor speutled on the Dack ol this(ortn. By requesGng the rebate check be mede <br /> payanle in the vendor, 1 2c�ree to fhe followin�: <br /> 1. I v+ili not receive a rebate chack dlrectly Irorn the City ol Everetl. <br /> 2. Assignmg payment ot the rebate io the vendor tices not ezempt mc irom Back�vater <br /> prevention Device Rebato Program requiremanta. <br /> I authorize the releare of my rebate to ihe vendor listed on Ihe bar.k of thi�form pending <br /> approval of tne complefed Backwater Piavenlion Devlce rebate packet by t�e City of Everett <br /> i <br /> U � <br /> Signature ot Property ner Da e <br />