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Eackwater P�evention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number: (City fo Provide) <br />Please complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: C A�P y c•, �a �:o __. <br />instal'a0on Address: /`/ia an T� s.T. __ <br />Ciry: _�'v<'!2 E�f1 State: _ titi A. Zip: 4 Fr,�o / <br />Mailin� Address (if diNerent): (��O • C3o,v �S � S <br />^ily: L�l'C-Alf'7Y State: �✓�. Zip: rY��i3 <br />Email: Phone: (yls) 3�'s • i3 y_j' <br />Total Cost to Instail Device (�rom contrar.fo� invoice): $��, q- ��YC/ <br />I, the property owner, request to have the Cily of Everett Backwater Prevention Device rebate check <br />for thr. inslallalion of ihe device at the above referenced property address be made payable to, and <br />sent to, the vendor sper.ified on the beck of this form. By requesting the rebate check be made <br />payable fo lhe ventlor, I agree to the following: <br />1. I will nol receive a rebate check directly from the City of Everett. <br />2. Assigning paymenl o( the rebate lo the vendor does not exempt me from Back�vater <br />Prevention Device Rebate Program requirements. <br />I authorize Ihe release of my rebate to Ihe vendor lisled on lhe back of this fnrm pending <br />approval of the completed 8ackvaater Prevention Devir,e rebate packet by the City of Everetl <br />y�� �--�' > <br />�� �-� ... — - <br />Signalure of Property Owner <br />� /'h' /.5 _ <br />Datc <br />