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Backwater Prevention Device <br />4rr Rebate Program <br />Vendor Section (please print): ) <br />Vendor Name / Business Name / UBI Number <br />7iClfcG'� qf)5 i\)L✓ <br />State of WashinUton Contractor License Numbei <br />,.7 VI /lti.6c', i C'tUF� --•--- —��1 c -�.� ` <br />Vendor Mailing Address City p� State Zip ^ Phone Email <br />I, the Vendor, agree to reDaive the Backwater Prevention Device rebate check directly <br />for the installation referenc•sd 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 file final <br />invoice given to the Property 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. 1, 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, 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 />� 1 j <br />ignature of Contractor /�; ro / <br />RiM,uut 9u3l2014 R.l,1t: 2 of 2 <br />