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Etackwater Preventian Device Rebate Program <br />VPndor Payrnent Option 1=orm <br />Project Number. ___.__ (C:ty fo f'rov�de) <br />F'lease complete both sides of the form <br />Property Owner Section: <br />Property Ou�ner Name: f�n l y ��-2 n _ <br />Insiallation Address: �7? 3��Q �� �-'�Q�' / fV`'Z- <br />City: %��%�C' 1 State: VT /� Zip:��JJ� <br />�vlailing Address (if diBerenQ: J I O� �lJ �4 <br />City: �•t l'� I State: �G'_/�__ Lip yQ�� � <br />Emai� �ree�� �QI. w�.�'i Phone:���%Sy-y3B� <br />o� <br />Total Cost lo Install Device (Irom contrector invoice): 5 n��Ci=�-� _ <br />I, the property otvner, request to have the City oi Everett Backv�ater Prevention Device rebate chec� <br />(or Ihe instaliation of lhe device at the abeve referenced property address be made payabie to, and <br />senl to, the vendor speci(ied on the back of this form. By requesting the rebate check be made <br />payable to the vendor, I agree to ihe followino: <br />i I�vill not receive a rebate check direcUy from the City of Everett. <br />2. Assigning payment o( th.e rebate to the vendor does not exempt me from 6ack�vater <br />Prevention DeviceRebate Program requirements. <br />I authorize lhe release of my rebate to lhe vendor listed on lhe back of this torm pending <br />approval of the completed Backwater Prevention Device rebate packet by ihe City of Everelt <br />�µ ��3/�Zo�S� <br />Signalure of Property Owner Date <br />