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. 1 • • <br /> � �� Bacikwater Pi•�vention Device <br /> ; Rebate Program <br /> Vendor Section (please print): <br /> � <br /> CP�n^+�Q�w� S Pt�viwg uJG, , l,sc. Ce.o-2 '�l� �,� <br /> Vendor Name/Business Na e/ UBI Number <br /> CA-v�P�Pr. �v� _ <br /> State of Washington Contractdr License Number: <br /> �.� . �o,� 55y�; ��,r�- �„�- a��c� <br /> Vendor Mailing Address City State Zip <br /> y7_5-Z5� - �i � 5� �n�r�-oCo.„��nziis - p�u�h��,• . o�, <br /> Phone j mail <br /> I, the Vendor, agree to receive,the Backwater Prevention Device rebate check directly <br /> for the installation referenced at the Property Address. By agreeing to receive the rebate <br /> check directiy, I agree to the fo�lowing: <br /> 1. The Backwater Prevention Device rebate amount will be deducted from the final <br /> invoice given io the I'raFerty Owner for the installation at the Property Address <br /> referenced above, iF the�total cost of the installation is greater than the rebate. <br /> 2. I, the Vendor, am a Washington State licensed contractor. <br /> 3. The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for <br /> the Backwater Prevention Device rebate payments totaling more than $600 per <br /> calendar year, anc' will report the same payments to :he Internal Revenue <br /> Service. i <br /> � <br /> I accept the direct payme�t of,the Backwater Prevention Device rebate from the City <br /> of Everett pending approval 01 the completed Backwater Prevention Device rebate <br /> package b e Cit f Everet <br /> —� <br /> �2 s � � <br /> Si nature of Contractor Dete <br /> � <br /> > <br /> � � Page 2 oi 2 <br /> Revised 913/2014 ! <br />