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i � <br /> Backw��t�r PrevEntion Device Rebate Program <br /> I ,� Verndar Payment Uption Form <br /> Projer,t Number: ____._,____ (City to Provlde) <br /> Please complete both sides of the form <br /> Property Owner Section: I <br /> I <br /> �— ------ — - -- — � � <br /> Property O::ner Name' _���'I a ��h'Q'___ — � I <br /> Installalion Address - --�' � �I � — — I <br /> City l�Pir' _ State:w� __^Zip_�p_�i� � <br /> Mailin�Address (i(c':tfererf)' _. _ —_._ <br /> , City: — State: •'-Ip: <br /> Email: �.���1Q1�.fI���Phone: (`{Z�' -,�j7i�' ,5�' <br /> Total Cost lo Inslall Device (fmm confractorinvoice): S�o'�_3v <br /> � <br /> � I, the property owner, request lo have the City o(Everell Backwaler Prevenlion Device rebate check <br /> for the i�slaliation of the device al Ihe above referenced property address be made payable to, and <br /> � senl to, the vendor specified on lhe back of this fonn By reyuestiny the rebafe r.heck be made <br /> payable lo the vendor, I agree to lhe following: <br /> t I will nol raceive a rebate check directly irom lhe City of Everetl. <br /> 2. Assigning payment of Ihc rebate lo lhe vendor does not exempl me from Backwaler <br /> Prevention Device Rebate Program requirements. i <br /> . <br /> I authori�e the reiease of my rebale to the vendor listed on ihe har.k of Ihis form pending <br /> approval of ihe completed Backwater Prevention Dnvir.e rebale packet by the City of Fvere�t <br /> _� � �� �l�,��_�� <br /> I �l/� � t l�--f l�-� �` <br /> I SignaWre of Property Owner Date <br /> '— - — -- - — --- <br /> � <br /> � <br /> � <br />