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/,� Backwater Prevention Device Rebate Pro�ram <br />�Y�� ��� Vendor Paymeri4 Option Form <br />��� <br />Prqect �l�mbcr. _ __ lCity to Provide) <br />Please cumplete both sides oi the form <br />Property C�wner Section: <br />Property Owrer Name: <br />z�P:_ ����_b�--- <br />tvtailing Address (il dillerent): _ _ <br />Total Cost lo Instal! Device (Irom contractor invoiceJ. $ <br />I, the pfoperty ov,�ner, request �o have the Cify of Everett Bacicwaler Prevention Device rebale check <br />`cr Ihe installatinn ol the device at the above rele�enced property address be made payable to, and <br />;r.nt to, the vendor specified on the back of this form. By requestir�g the rebate r,hech be made <br />paya6le to the vendor, I agree to thc followiny: <br />1. I �vill not receivc a rebatr, check directly Irom the City ot Everett. <br />2 Assigning payment ol the rebate to Ihe vendar does no� exempl me from Backwater <br />Prevention Device Rebale Program requiremenls. <br />I authorir^ the ralease ol my rebate to Ihe vendor listed on the back of this form pending <br />approval of the completed Backc+atr.r Prr.vention Devlce rebate packef by Ihe City ol Everett <br />/ � � ��� V /�1� <br />��-Z <br />Signature of Praperty Owner Dale <br />----- __------_ _ __ _ __�_—� <br />