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� Backwater Prevention Device Rebate Program <br />Vendor Payment Option Form <br />Project Number. (City to Provide) <br />Please ��mplete both sides of the form <br />Property Owner Section: <br />Property Owner Name: <br />Installation Address: _�Jjf_ <br />City: ���P� <br />Mailing Address (iI dilferenQ: <br />� � <br />Zip:_�� _U (_ <br />City: State: _ Zip: <br />Email: . �� ��1�;{1. Coj� Phon« (�ls) �_(�5_ <br />Tolal Cosl lo Ins�all Device ((rom con(rac(orinvoice): S__p��a�•_g� _ <br />I, ihe property owner, requesl lo have ihe Cily of Everelt Backwater Prevention Device rebate check <br />for lhe inslallation of the device al ihe above referenced pwperty address be made payable to, and <br />sent to, the vendor specitied on the back of lhis form. By requ �s�+ng the rebate check be made <br />p:iyahle to ihe vendor, I agrce lo the following: <br />1. I v+ill nol receive a rebale check direcUy from lhe City ol Everetl. <br />2. Assigning payment of the rebatc to thc vendor does not exempt me from Backwater <br />Prevention Device Rebale Proc�ram requiremenls. <br />I authorize lhe release of my rehate to the vendor lisled on lhe back of Ihis fnrm pending <br />approval of ihe cornpleted Eiackwaler Prevention Device rebate packel by the City ot cv�rett <br />--�-X^� � �"" - � ' — r n ` - <br />U' / <br />Signature of Property Owner bale <br />