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ac titer 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; <br /> Installation Address: iVnet k or '. <br /> 9D-6 I <br /> City ' P State: •Zip; <br /> Mailing.Address(if different): <br /> City: State:, Zip: <br /> Email: Phone: <br /> Total Cost to Install Device(from contractor invoice): ' 10, <br /> I,the property owner, request to have the City of Everett Backwater Prevention Device rebate check <br /> for the installation of the device at the above referenced property address be made payable to,and <br /> sent to,the vendor specified on the back of this form By requesting the rebate check be made <br /> payable to the vendor,I agree to the following: <br /> 4. I will not receive a rebate check directly from the City of Everett. <br /> 2. Assigning payment of the rebate to the vendor does not exempt me from Backwater <br /> Prevention Device Rebate Program requirements.. <br /> I authorize the release of my rebate to the vendor listed on the back of this form pending <br /> approval of the completed Backwater Prevention Device rebate packet by the City of Everett <br /> Signature of Property Owner Date <br />