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i <br /> , <br /> � <br /> � �ackwrater Prevention Device Rebate Program � <br /> Vendor Payment Option Form ; <br /> i <br /> Projecl Num6er: _(City to Provide) � <br /> � <br /> f <br /> Please complete both sides of the form � <br /> ; <br /> Property Owner Section: ! <br /> — —L�l�.�� ; <br /> Property Owner Name: �. <br /> Inslallalion Address: ���� ,�� � � j <br /> ��{- Stale:W A Zip:�l- ,�j�o� ! <br /> CI�Y��` '�-� <br /> Mailing Address(if dilferenQ:��k � <br /> aSU� ` <br /> Cily: �vr_}_� Stalc: ��Zip: `�1� r��K, <br /> Email: 1��faT�-_�O F�l-�(R��V1 0 •�R Phone:�c�'9 aS,$24G� <br /> Total Cosl lo Inslall Device(from contrector Invoice): S �•��C�y' <br /> � ----- — - - <br /> I,the properly owner,requesl to havc� lhe City of Everel�[3ackwater Prevention Devicct rebale check <br /> 1or lhe installation of the device at the a6ove referenced properly address be made payable lo, and <br /> s mt 10,the vondor specified on Iho bach o(Ihis form. By requesling the rebale check be made <br /> payable to lhe vendor, I agree lo the(ollowing: <br /> 1. I will nol receive a rebate check direclly Irom lhe Cily of Evorell. <br /> 2. Assigning payment of tho rebate to the vendor does nol exempt me from�ackwater <br /> Prcvention Devic� Rebalr. Program requiremenls. <br /> I aulhorize the rcleaso of my rebale lo lhe vendor listod on the back of lhis form pending <br /> approval of Ihe compleled Hackwaler Prevenlion Device rebate packel by the City of Everett <br /> � U � �U �7 �� <br /> � . , nc� cQ �� <br /> Signat e o Prope y O ner Dale <br />