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� �` ! i ' � <br />y � �.. • d <br />1� i � <br />� ' i �s` ,, � .� � � <br />� ' �: <br />���� <br />i � ♦ /' <br />� . � +.. <br />please complete both sides vf the form <br />p��-�p��� Qwrner Section: <br />� <br />Property t�wner Name: <br />l�stailation Address: " d ' ' � j <br />_ Sfiate: ____ ZiP: C7 � l.---------- <br />City: � r� , r•�. �. �_ � <br />I�lailing Address {if dtfferent): -�. <br />�ity: � t��' �-�� <br />State: l�� � Zip: � � 7-��.� � <br />�m���: <br />Tatai Cost ko Install Device {from cnntractorinvoice} <br />phone: (� -_ <br />�y► � � <�t� <br />1, the prap�rty Qwner, request to have the Cit�efe enced p ope ytaddress bte m de payabie toGandk <br />for ihe installation ofi the cievice at the above <br />sent to, the vendar specified on the bf�c�i of`nhis 'fdrm. By requesting the rebate check ba made <br />payable ta the vendor, I agree to the 9 <br />1, I wiN not receive a rebate check directly from the Gity of Everetf. <br />2. Assigning payment of the rebate ta the vendor does not exempt me from Backwater <br />Rr�v�ntion Devi�e Rebate Prograr� requirements. <br />1 autharize the r�fease of my rebate to t euer�itioorDev�c�e rebate packet by t e� Gifiy nfi�E Er�tt <br />approval of the compl�ted Backwater Pr <br />, � �.�:��F �;.� `�� � <br />Signature of Praperty Owner <br />��,�%.����-F <br />aate <br />