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Backwater Prevention Device <br />Rebate Program <br />Vendor Section (please print): <br />► �, c_—�_(y U2 �1 ��.� � �j`� <br />Vendor Name / Business Name / U81 Number � <br />� r�n�PGA :i J1� +]n�___� <br />State of Washington Coniractor License Number: <br />�—L �cti `�5�-{ I _�v-C-F.= i i 'v_�A cl �5��, _– <br />Vendor Mailiny Address Cit State p <br />�2`� 25��i- >;stiF� S�rv,« J��� � z� <br />------- 017�-�IS f�IvmlL�'�c� , i,•��nn <br />Phone Email <br />I, th� Vendor, agree to receive the Backwater Prevention De!ice rebate check directly <br />��r the install2tion referenced at the Property Address. Qy agieeing to receive thc rebate <br />check directly, i agree to ihe foliov,�iny: <br />i. The Backwater Prevention Device rebate amount �vill be deducted irom the final <br />invoice given to the Property Otvner for the installation at the Property Address <br />referenc�d 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 />3. The City of Everett will send a Federal Form 1099 �41SC to me, ihe Vendor, for <br />the Back�v2ter Prevention Device rebate payments totaling more Ihan $600 per <br />calendar year, and wili report ihe same payments to the Internal Revenue <br />5 e rvice. <br />I accept ihe diiect payment of the Back�vater Prevention Device rebate from the City <br />of Everett oending npproval of the �ompleted Backwater Prevention Device rebatr. <br />package by the_�'�f Everett <br />— - ; �� <br />� <br />`� . ' - <br />�/ � �1--- �7��%/ - <br />Siynatu� ol Contractor Date <br />Revised 9l3/20'14 Page 2 of 2 <br />