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� <br />A►�►-�" <br />Backwater Prevention Device <br />Rebate Program <br />Vendor Section (please print): <br />Business Name / UBI Number <br />��•r <br />Slate of Washington Contrector License <br />�-�-1,z �z�� c� S.a,, d.� <br />Vendor Mailing Address <br />Phone <br />[mail <br />�.�'�S'��� <br />:��1 qgo�G <br />State /1 Zip / <br /><P�.u¢.l^ / �i (�ict� /. Coa�l <br />I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly <br />for lhe instaliation referenced at the Property Address. By agreeing to receive the rebate <br />check directly, I agree to the following: <br />1. The Dackwater Prevention Device rebate amount will be deducled from lhe final <br />invoicc yiven lo lhe Property Owner for lhe installation al ihe Prop�rty Address <br />referenced above, if the total cosl of lhe installation is greater lhan lhe rebate. <br />2. I, ihc Vendor, am a Washington State licensed contractor. <br />3. The City of Everettwill send a Federal Form 1D99 MISC to me, the Vendor, for <br />the Backwaler Prevention Device rehate payments totalinc� more than $600 per <br />calendar ycar, and will repori the same paymenls lo lhe Internal Revenue <br />5ervice. <br />I accept the direcl payment of the E3ackwater Prevenlion Devir.e rebale fiom lhe City <br />of Fverell pending approval of 1hr completed Backwaler Prevention Devicc rebate <br />package by lhe City of L'-verett <br />� �����= <br />Si - a i e ol Confracfor <br />Revised 9/3l201� <br />�a� -��s' <br />Da(e <br />Pagc 2 uf 2 <br />