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Backwater Prevention Device <br />EVE TT Rebate Prograrn <br />Vendor Section (please print): <br />Verdor Name / Business Name / UBI Number <br />Slate of Washington Contractor License Number: <br />? <br />e.-J '_-- <br />Vendor Mailing Address City Stale Zip <br />Phone Email — <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 directly, I agree to the following: <br />1 The Backwater Prevention Device rebate amount will be deducted from flip, final <br />invoice given to the Property Owner for the installation at the Properly Addre.;:; <br />referenced above, if the total cost of the installation is greater than the rebate <br />2. I, the Vend•x, am a Washington Stale licensed contractor. <br />3. The City if 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, and will report the same payments to the Internal Revenue <br />Service. <br />I accept the direct payment of the Backwater Prevention Device rebate from the City <br />of Everett pending approval of the completed Backwater Prevention Device rebate <br />package by the City of Everett <br />Wl" L <br />61 <br />i! <br />. igoature ofContrartor Data <br />Rovisod 9/312014 Pago 2 of 2 <br />