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� Backwate,- Prevention Device Rebate Program <br />Vendor Payment Option Form <br />I-rojecl Number. _ __ _ (Cify to Pn;vide) <br />Please complete both sides o� the form <br />Property rJwner Section: <br />Properly Owner Name: �Q4t'U Vl« �- •�JQCe.'}l-c�1 _ <br />Inslallation Add�ess: �C� <br />Cily: ��i�QLt.Qi� _ <br />Mailing Address (il dillerent): _ <br />City: <br />State: <br />Slate: <br />Zip: �� ZO <br />Email� I1nG � V�GG-I I,ei� (CLL� • CA�^ Phone� ��1.� �J3 �- I l Y% <br />---� <br />Total Cost lo Install Device ((rom confractorinvoir.e): $ �� �93-������ <br />-- - - -- ���v "`' --- <br />1, lhe property owner, request lo have the Cily o( Everetl Backwater Prevention Device rebate check <br />for the installalion of the device at lhe above referenced property address be made payable lo, and <br />sent lo, the vendor specified on the back of this form. By reyuesliny the rebate check be made <br />payable to the vendor, I agree lo lhe lollowing: <br />1. I will nol receive a rebale check directly from the City ol Everetl. <br />2. Assigning payment o( the rebale lo lhe vendor does not exempt me from dackwaler <br />Prevention Device Reha�e Proc�ram requirernenls. <br />I aulhorize Ihe release of my rebate to the vendor listed on lhe back of �his form pending <br />approval of lhe compiefed Back�vater Prevention Device rebale packet by the Cily of Everett <br />���1��.t��l�(Gf�-!�✓ �11Vk+c. PJ�� <br />Signature of Property vmer <br />�/ (5 -- <br />Dale <br />