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Backwater Prpvention Device <br /> E� Rebate Program <br /> Vendor Section (please print): <br /> Ct�n�P6�U.'S �A���l�(`2� �n:L . / ILOZ ���2.� IC1 1 <br /> , Vendor Name/Dusiness Name! UBI Number <br /> CA��iPGA t q �� � n — <br /> State of Washington Contractor Licen;e Number. <br /> , U . �'�o_� `J5L{ I �v�E!�c� v�r-1 �"l �S2t_.`�a <br /> Vendor Wlailing ?,ddress Ciry State Zip <br /> Z�� 5_- �5��i - �%s9K Se����te �J �U,M����ils Plv��b�'���� , ���� <br /> Phone Email <br /> i, the Vendor, agree lo receive the Backwater Prevention Device rebate check directly <br /> for the installation referenced at the Property Address. ay agreeing to receive the rebale <br /> check directly, I agree to the fol�o�ving: <br /> 1. The [3ackwater Prevention Device rebate amount v✓ill be deducted from the final <br /> invoice given to the Property Owner (or the installation at the Property Address <br /> referenceU above, if the total cost of the installation is greater than the rebate. <br /> 2 I, the Vendor, am a Washiiigton State licensed contractor. <br /> 3. The City of Everett will send a Federai Form 1099 MISC to me, the Vendor, for <br /> lhe Qacl<water Prevention Device rebate payments totaling more than �i�GO per <br /> calendar year, and will report ihe same payments to the Internal Revenue <br /> Service. <br /> I accept ihe direct payment of the Backwater Prevention Device rebate from the City <br /> of Everett pending approval of the completed Backwater Prevention Device rebate <br /> packayo by the City of Lverett <br /> ��1� � �„�s� D� <br /> �!' /s' <br /> Si,qnature o/Contrar.tor D� !n <br /> Page 2 of 2 <br /> Revised 9/3/2014 <br />