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0 Backwater Prevention Device <br />Rebate Program <br />Vendor Section (please print): <br />CInFg:l.U�_Lu�� IrUh ANC (1/�� <br />Vendor Name /Business Name i UBI Number -- <br />cAf�,ar)p,- 01-1 <br />State of Washington Contractor License Number: <br />U F_,OIL <br />Vendor Mailing Address t�A ct 1�2 <br />City �l 1,Slalo Zip <br />5ervlt�"V CL\'% ()eII5 �Vrti'1�)rrl <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 the 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. I, the Vendor, am a Washington State licensed contractor. <br />I 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 th'e 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 t_he ti' f Cverett <br />-- <br />Signal of Contractor <br />Revised 91312014 <br />Date <br />Page 2 of 2 1 <br />