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Backwater Prevention Device Rebate Program <br /> �. Vendor Payment Option Form <br /> Projecl Numbor (City to Pro��ide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> � Properly O�vner.Name: _ _��Hc\y �hs-an _- -- --- _ � <br /> �nstallalion Address -- -���8---[��G ��li - �f/�---- --- <br /> Cily: �f�^�G� State: W�__ Zip:���� � <br /> i tviailing Address(i(diHerent): <br /> City: _ State: Zip _ _ <br /> Email: _ __ Phone: ( ) _ ____ <br /> i Total Cosl to Install Device (from confracfor invoiccf 5?,Sae i <br /> `--- ----- -- - --- - <br /> I, the property owner, request to have the Ciry of Everetl Rack�vater Prevention Devic.e rehate cher.k <br /> for fhe insta�la�ion of the device at the ahove referenced property address be made payable to, anc <br /> sent to, ihe vendor specified an Ihe back of tlus form By reyuesting the rebale check be made <br /> payable to lhe vendor, I agree lo the lollowing <br /> 1 I �vill nol recerve a rebale chech direclly fwm the City o( Everelt. <br /> 2 Assignin� payment of lhe rebale lo Uie vendor does not exempt me franr�acke�atcr <br /> Prr.ventinn Device Rabate Program requiremenis. <br /> - - i <br /> I authorize Ihe rr.lease of my rebate to the vendor listed on the back of thls fonn penSng I <br /> � approval o(Ihe r.ornpleted'B�ckwater Prevention Dewce rel�ate packet by the Cdy of Cve:relt I <br /> i <br /> -- -- -- - --1��zt"S� I�� <br /> I - <br /> Signature ot Property 0�•�ner Date j <br /> --- - -- — - - ----- --- - _ 1 <br />