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Backwater Prevention Device Ref.�ate Program <br />Ev Vendor Payment Optinn Form <br />Prujecl Number: (Cify to ('rnvi�e) <br />Plea�e complete both sides of the form <br />Property Owner Section: <br />Property Owner Name: �o U '�� <br />Installation Address: a� r� �.i�'/�li+ � i`� <br />City: �%��� State: �� Zip: �+�ZU� <br />Mailing Address (iI dirferent): <br />City: State: Zip' <br />Email: <br />Phane: ( ) <br />Total Cost to Inslall Device (from confracforinvoice): $<`'J �L� <br />I, the property owner, rn�piest to have the City of Everett Backwaler PrevenliomDevice rebate check <br />(or the inslallation.of the device at the above referenced property address be made payable lo, and <br />sent to, the vendor speci6ad on the back of this (orm. By requesting the rebate check be made <br />payable to the vendor, I agree to the follo�ving: <br />1. I will not receive a rebate check directly from lhe Cily of Everett <br />7.. Assigning payment of lhe rebate lo the vendor does not exempt me from Backwaler <br />Prevention Device Rebale Program requirements. <br />I authorize the rclease o( my rebale lo lhe vendorJisled on the back �f this form pending <br />approval o( the completed t3ackwater Prevention Device rebate packet by ihe City of Everelt <br />O` Ca.w'-� !� -� � �i - 2 �/— / S� <br />Signature o(•Property Owner Date <br />