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� <br />B��ckwater Prevention Device <br />Rebate Program <br />Vendor Section (please print): <br />U'L <br />Vendor Name / Business Name / U61 Number <br />. „ __ ,. � ,. <br />��Z� q��f <br />State of Washington Conlractor Lic�nse Number: <br />, u. fie: 55� i r=_ v�`-r� c,•.q `t 821. <br />Vendor Mailing Address City State <br />�tZ`; - ZS�i -�>89FS Serv i�N � Ca,M Z�P <br />P'one — PUei�S" ��v�v��;r1 . Ci,�v1 <br />h Emafl � <br />I, the Veiidor, ag;ee (o receive the Ba�akwater Prevention Device rebate r.heck direclly <br />for the inst��llatio � referenced al the Properfy Address. By agreeing to receive the rebate <br />check direetly, I�gree io tne fallowing: <br />1. The Backwater Prevenlion Device rebate amount will be deducted trom the final <br />invoice given to the Property Owner tor the instaliation at the Property Address <br />reierenced above, if the total cosl of the installation is greater than the rebate. <br />2. i, the Vendor, am a Washinglon State licensed contractor. <br />3. 7he City of Fverett will send a Federal Form 1099 MfSC to me, the Vendor, for <br />the Backwatcr Prevention Device rebate payments totaling more than $600 per <br />calendar year, �nd will report th� satne payments to the Internal Revenue <br />Service. <br />I accept ihe direcl payment of the Backwater Prevention Davi�e rebate irom the Cily <br />of Everett pending approval of the completed Backwater Prevention Device rebale <br />packagc hy the C�ty�f Everelt <br />.. — .l- � /� � <br />of Contractor <br />�' �� l.S <br />Dale <br />Rrvi��ed 9/3/2U1q f'a�u 2 p} Z <br />