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Backwater Prevention Device Rebate Program <br /> i Vendor Payment Option Form <br /> I <br /> � Project Number. (City to Provide) <br /> � <br /> � <br /> I <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> I <br /> Property Owner Name:�}y�N p 0 L �N k, t�� N �0 <br /> Inatallalion Address: _�9I� �'Y�% M D �� �'V�. ___ _ <br /> c�iy: E V F R�T� state: 1N/} zip: 9 8' Zo I— 22`f 3 <br /> Maiiing Address(i(diNerent): __.. _ _ _s/T / ( � <br /> City: State:____ _Zip: <br /> Emait:_ ��/� Phone (NA6j 25�� — 95"�6 <br /> Total Gost to Inslall Device((rom cont�actor invoice):$ _ <br /> i <br /> II, the property owner, request to have the Ci1y of Everett Backwater Prevention Device rebale check <br /> (or the installation of the device at the above referenced property address be made payable lo, and <br /> sent to,the vendor specified on ihe back of lhis form. By requesting the rebale check be made <br /> payable to the vendor, I agree lo lhe following� <br /> 1. I will nol receive a rebate check direclly from lhe Cily of Everell. <br /> i 2. Assignir_� paymenl of the rebale to the vendor does nol exempl me from Backwaler <br /> I Prevention Device Rebate Program requirements. <br /> I <br /> I aulhorize lhe reiease of my rebate lo lhe vendor lisled on Ihe back of lhis fonn pending <br /> �pprovel of the completed Back�vater Prevention Device rebalo packel by the City of Everet! <br /> � <br /> � <br /> —,�°�r '�` ` ��' ---- z0� I <br /> I Signature ot Pr perty O�vne D e <br /> 1 <br />