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Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Projed Number: (Crty to Provide) <br /> Piease complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: � � lP.-Y ��.0 3'S <br /> Installation Address: 7 ZZ��� ��-�- 7 j4�-"�'�� <br /> City i `fi State: ����' Zip. !d `��� <br /> Mailing Address (ildillerent): <br /> City: Slate: Zip: <br /> Email: Phone���2� y��'c� <br /> �) �j O <br /> Total Cost to Install Device (/rom conlracfor invoice): S �U�" �-�- � _ <br /> I, the propeAy oe+ner, request to have the City of Everett Back�vater Prevention Device rebale check <br /> for the installation of the device at the above referenced propeAy address be made payable to, and <br /> sent to, the vendo�specified on the back of this form. By requesting the rebate check be made <br /> payable to the vendor, I agree lo the following: <br /> t. I will not receive a rebate check directly from the City of Everett. <br /> 2. Assigning payment of the rebale to the vendor does not exempt me irom Backwaler <br /> Prevention Device Rebate Program requirements. <br /> I authorize the release of my rebate to the vendor listed on the back of this form pending � <br /> approval oi the completed Backwater Prevention Device rebate packet by the Ciy oi Everetl <br /> �c_, tYju�`-- J 2-t (�—� �— <br /> Sign ure of Property Owner Date <br />