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' <br /> Backwater Prevention Device Rebate Program <br /> Vendor Payment Option Form <br /> Project Number-. (City to Provide) <br /> Please complete both sides of the form <br /> Property Owner Section: <br /> Property Owner Name: Vfl"- ij <br /> Installation Address: <br /> Mailing Address (if different): <br /> City: State: Zip: <br /> Email: Phone: <br /> Total Cost to Install Device (from contractor invoice): $ <br /> | the pnope�yowner, request tohave the{�itynfEverm�Backwater Prevention Device rebate check <br /> for <br /> sent to, the vendor specified on the back of this form. By requesting the rebate check be made <br /> payable tnthe vendor, | agree hothe following: <br /> 1. | will not receive arebate check directly from the City ofEverett. <br /> 2. Assigning payment ofthe rebate tothe vendor does not exempt mafrom Backwater <br /> Prevention Device Rebate Program requirements. <br />