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i <br /> � <br /> Backwater Prevention D�evice <br /> Rebate F�rogram <br /> Vendor Section (please print): <br /> f 1 f'"..'R-�) ��tn 1 I N Ll.. C LD� 3 ^-i-`Z.�' ��(Q _ <br /> Vendor Name/Business Name/UBI Numbr.r <br /> �l�-�n P P�-Rc�3 n�2 <br /> Slate of Washinglon Contractor License Number: <br /> gb 6C�x �3�-1 Scvot�om�s(� w�_ 9829 / <br /> Vendor Mailing Address City Stale Zip <br /> r20(r �- 4DLe—�2� "�re.�rC'oll�NrS �) �Noo ,eo� <br /> Phone Email <br /> I, the Vendor, agree to receive the Backwaler 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 rebale amount will be deducted frorn the final <br /> invoice given to the Property Owner for the installation at the Property Address <br /> referenced above, if the total ost of the installation is greater than the rebate. <br /> 2. I, the Ve�dor, 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 �ebate payments totaling more than $600 per <br /> calendar year, and will report the same paymenls to the Internal Revenue <br /> Service. <br /> I accept the direct payment of the Backwater Prevention Devic� rebate from the City i <br /> of Everett pending approval of the completed Backwater Prevention Device rebate � <br /> package by the City of Everett � <br /> � <br /> �� �_ -� _ /_ v ! <br /> Srgnature of Contractor Date <br /> Page 2 of 2 <br /> Revlsed 9/3/?.014 <br /> � <br /> � <br />