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� Backvvater Prevention Device Rebate Program <br /> Vendor Payment f�ption Form <br /> Projecl Number. (City fo Pn�vide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: ��� P.P'�-Y "�" �"V1/�`� � ��/��'LlJ`.Ll/Li <br /> InstallationAddress: I �D �L�— �.}-� 1 �Vw rC -/^C�l-��`�VlQi <br /> City: �r"�1.� ___State: lJ�-�` 2ip:_� �-� l <br /> Mailing Address (i(dillerenf): �'7 l 2-.�� �J��7� �'� � <br /> City: E�–v't'l'C��� Stale: 1.�� Zip:L(–p �--�J✓ <br /> Email: QS/V�. 6'�inV�c�/t� ��hon (e.�t(�S ��J�J 2�� ' <br /> � Tolal Cost lo Install Device ((rorn contractor invoice): $ :L�"� ( ,�� <br /> I, lhe properly owner, request lo have lhe Cily of Everell Backwater Prevenlion Device rebale check <br /> for ihe installalion of Ihe device at the above referenced property address be made payable lo, and <br /> sent to, the vendor specified on the hack of this form. By requesting Ihe rebate check be made <br /> payable lo lhe vendor, I agree lo lhe following: <br /> 1. I will not receive a rebate check directly(mm Ihe City of Everett. <br /> 2. Assignin� paymenl of lhe rebate to lhe vendor does not exempt me from Bar.kwaler <br /> Prevenlion Device Rebate Program requirements. <br /> 1 authorize the release of my re6ate to the vendor listed on the back of this form pending <br /> approval of Ihe cornpleted Bar.kwater Prevention Device rebale packel by the City of Everetl <br /> _' l,C' � ��1� <br /> SignaWre Properl wner flale <br />