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i - - . . _ <br /> � - <br /> � <br /> '; Backwater Prevention Device Rebate Program <br /> � <br /> � Vendor Payment Option Form <br /> � <br /> Project Number. (City to Provide) <br /> i <br /> ; Please complete both sides of the form <br /> � Property Owner Section: ; <br /> IPropertyOwnerName: Too � �}NrJ SM�Ttii _ <br /> i <br /> Installation Address: Z� � W CTMoac Av E <br /> Cily: EV�C� Slale: wA- Zip; 48zot <br /> � Mailing Address(il diNerent): <br /> City: Stale: Zip: <br /> Email: '.ia+.+s��11 �nu����w�C��tioo c o.n Phone: (�u) 259- �0 6$ <br /> Total Cost lo Inslall Device ((rom contracfor invoice): 5_�.'�� • �� — <br /> i <br /> ! I, lhe properly owner, request to have the City of Everett Backwater Prevention Device rehate check <br /> i for the installation of the device at the above referenced property address be made payable lo, and <br /> sent to, tlie vendor specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree to the following: <br /> 1. I will not receive a rebate check direcUy from the City of Everelt. <br /> 2. Assigning payment of the rebate to the vendor does not exempl me irom Backwaler <br /> Prevenlion Device Rebate Program requirements. <br /> I authorize the release of my rebate ro the vendor listed on the back of Ihis form pending <br /> � <br /> approval oi lhe compleled Backwater Prevention Device rebate packet by the City of Everett <br /> �'�, ���� v ��—�4 � �.�_i�-zo i y <br /> Signature of Property Owner • Date <br /> I <br /> I <br />