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�' <br />Backwater Prevention Device <br />Rebate Program <br />Vendor Section (please print): <br />ll�aa Pr,�„� 3,N� �ao3 -42-5- o� r� <br />Vendor Name ! Business Neme I UBI Number <br />State of Washington ConVactor License Number. <br />Hrsrtvvocf3ce�Ns. <br />Vendor Mailing Address City State Zip <br />P[� 6ox �36`( S'n+oNorK�s�l ww, 9E�29 / <br />Phone aOfo -�{�(n _p �' 29 Emafl TrFe�'f'Cp(: �� e+✓-4 � S/pElpp .Cnn1 <br />I, the Vendor, agree to receive the Backwater Prevention Device rebate check direcdy <br />for the installation referenced at the Property Address. By agreeing to receive the rebate <br />check directly, I agree to the tollowing: . <br />1. The Backwater Preventlon Device rebate amount will be deducted from the final <br />invaice given to the Property Owner (or the installation at the Property Address <br />referenced above, if the total cost oi ihe installation is greater than the rebate. <br />2. I, Me Vendor, am a Weshington State licensed conVactor. <br />3. The City of Everett will send a Federal Fortn 1099 MISC to me, the Vendor, for <br />the Backwater Preven8on Device rebate payments totaling more than $600 per <br />calendar year, and will repoR the same payments to ihe Intemal Revenue <br />Service. <br />I accept the direct•payment of the Backwater Prevention Device rebate irom the City <br />of Evereri pending approval nf the completed Backwater Prevention Device rebate <br />package by the City of Everett <br />�Li/<��� /2-2-/g <br />Signature of Conhactor <br />Date <br />• Page 2 of 2 <br />Revised 9/3/2014 ' <br />