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Ba�kwater.Prevention Device <br /> : Rebate Program <br /> Vendmr Section (please r�:•int): <br /> � �� ��--�.��-}—�u�. r �O�Z �lz,c� °I°►�I . <br /> Vendor Name/ Business Nanje!UBI Number <br /> C_�rv�Q �S�►'1 �1� � - <br /> St te of Washinyton Contractor License Num6er: <br /> - �� � �1;—,-�=.�-�� �.�,�- �j�7�(� <br /> Vendor Mailing Address City State Zip <br /> " �Z5-7� -3F�'��( �e_�,•, :.e�7Ca��e�ls- d�rH �jIJIG �CD�M <br /> Phone Emaii <br /> I, the Vendor, agree to receive.the Bac;;.;ater Prevention Device rebate check directly <br /> for the installation referenced at the Property AddrE;ss. By agreeing to receive the rebate <br /> check directly, I agree to the following: <br /> 1. The Back�vater Prevention Device rebate amount will be deducted from the final <br /> invoioe given to the ProF�erty Owner for the installation at the Property Address <br /> referenced above, if the itotal cosi of the installation is greater than the rebate. <br /> 2. I, the Vendor, am a Washington 5tate licensed con}ractor. I <br /> 3. The City of Everett will s�end a Federal Form 1099 MISC to me, the Vendor, for <br /> the Backwater Preyentidn Der•ice rebate payments totaling more than $600 per <br /> calendar year, and will report the same payments to the Internal Revenue <br /> Service. <br /> I accept the direct payment of�the Back�vater Prevention Device rebate from the City <br /> of Everett pending approval of the completed Backwater Prevention Gevice rebate <br /> package b ity of Ever tl. <br /> Signatu ofContractor Dat�� <br /> Page 2 of 2 <br /> Rpvised 91312014 <br />