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Backwater Prevention Device Rebate Program <br />Vendor Payment Optinn F'orm <br />Project Number: (Cify to Provide) <br />Please complete both sides of the form <br />Property Owner Section: , <br />Property Owner Name: �u.ccl , Na�pe� <br />Inslallation Address: l �//U 3S� � S'r' <br />City: �vere-Yf- State: w'i' Zip: �f��l <br />Mailing Address (if di(ferent): <br />City: <br />State: <br />Email: Phone: (��i�) 2�G— 3Nl,f' <br />Total Cost to Install Device (from contracfor invoiceJ: S.Zi SGG.� <br />I, the property owner, request to have the ;ity of Everett Backwater Prevenlion Device rebate check <br />for the installation of the device at the abo�. e referenced Property address be made payable to, and <br />sent to, the vendor specifed on the back o�` this form. By requesting the rebate check be made <br />payable to the vendor, I agree to the following: <br />I 1. I will not receive a rebate check direclty from the City of Everett. <br />i <br />2. Assigning payment of the rebata to the vendor does not exempt me from Backwater <br />Prevention �evice Rebate Ptogram requirements. <br />I authorize the release of my rebate to lhe vendor listed on the back of this form pending <br />approval of the compleled Backwatar Prevention Device rebate packet by the City o( Everett <br />Signature of Property Owner <br />�3��. <br />Date <br />