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Backwater Preventiora Dpvice Rebate Progra►r� <br /> Vendor Payment Option Form <br /> Projecl Number: (Cify to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property O�vner Name: �a�y�}��Fgpr� <br /> Installation Address: 25�3 Maple St <br /> City: Everelt Slate: WA Zip:.gg2(�1 <br /> Mailingllddress (ildiKerent): - <br /> City: Slate: Zip: <br /> Emaii: Phone: ( ) <br /> � � <br /> Total Cosl to Install Device (Irom contractor invoicef. $����� <br /> I, lhe property o�vner, request lo have the City of Everelt Backwater Prevention Device rebate check <br /> for the installation of lhe devicc al the above re(erenced property address be made payable to, and <br /> senl to, �he vendor specified on�he back of this form. By requesling the rebale check be made <br /> payable lo ihe vendor, I agree to ihe following: <br /> 1. I will nat receivc a rebale check directly(rom the City of Everelf. <br /> 2. Assigning paymenl of the rebate to Ihe vendor does nol exempl mc(rom Backwaler <br /> Prevention Device Rebate Program requirements. <br /> I aulhorize Ihe release oi my rebale to lhe vendor listed on the back of this form pending <br /> approval o(ihe completetl Backwater Prevention Device rebale packet by the City of Everett <br /> Saovr.r�ur,t�ta f-le�ersurz July 9th, 2015 <br /> Signature of Property Owner Dale <br />