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Sackwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number: (Cily fo Provide) <br /> PleasP complete both sides of the form <br /> Property Owner Section: <br /> � <br /> Property Owner Name: J �C�.rl rl�� <br /> InslallationAddress: � J�� a�� �� <br /> city: Cvt�.rl?-4-�- state: lJfi zip:�YJo20 ) <br /> Mailing Address (il differentJ: <br /> City: State: Zip: <br /> Email: �_ �GL�1 �tX��S-1� 0.hCo. _Orr Phone: (4�) 31� -5g� 1 <br /> T—�— c� 2� <br /> iotal Cost lo Install Device (lrom contractorinvoice): S � � (JLI .�lJ <br /> I, the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at the above reterenced property address be made payable to, and <br /> sent to, the vendor specitied on the back of�this form. By requesting lhe rebate check be made <br /> payable lo the vendor, I agree lo the following: <br /> 1. I will nol receive,a rebate check directly from the City of Everelt. <br /> 2. Assigning payment of lhe rebate to lhe vendor does not exempt me from Backwater <br /> Prevenlion Device Rebate Program requirements. <br /> I authonze Ric release of my rebate to the vendor listed on the back of this form pending <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> ��. � a s <br /> i nature of Prop rty Owner Date <br />