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Backwater Prevention Device Rebate Program II <br /> t„ Vendor Payment Option Form i <br /> Project Number. (City fo Proviae) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> � - <br /> Property Ovmer Name: ���P� � �n���'C <br /> Installation Address: �W���CJ' ' " / <br /> City: �l)P.vP.l:"7 __Sfale: _�._�-r_Zip:���( <br /> Mailing Address(if diflerent): �J __ <br /> Ciry: State: _Zip: <br /> 2 ' 2�a� �35 <br /> Email: Plione: ( � ) <br /> Q' I i <br /> Tolal Cost to Inslall Device ((ram confractorinvoice): S��Vy ' <br /> I, Uie propeAy owner, requesl lo have the Ciry of Everetl Backwater Prevention Device rebate check <br /> for the inslallation oi the device al the above referenced property address be made payable to, and <br /> + senl lo, lha vendor specified on the bar,k of this torm. By requesling lhe rebate check be made <br /> � payable lo the vendor, I agree to the(ollowing: <br /> I L I will not rec aive a rebate check direcUy irom the City of Everell. <br /> Z. Assigning payment a(Ihe rebate to Ihe vendor does nol exempt me Irom 8ackwater <br /> Prevention Device Rebale Proyram requiremenis. <br /> � -- -- — i orm endin - -- <br /> I aulhorize Ihe rclease of my rebale to ihe vendor lisled on the back of lh s f p g <br /> approval of Ihe compleled Backwater Prevention Device rebate packet 6y lhe City of Everelt <br /> _�e�d�`� J (.Q <br /> SignaWre o(Property Own Da�e <br />