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� � Back�nrater Prevention Device <br /> Rebate Program <br /> � <br /> � <br /> Ven;dor Section {please p�int): I <br /> • <br /> I <br /> i G ' <br /> C�����Ps�u�S_�um iv� In,�c . ��'��- `'12-� � �`� , <br /> Vendor Name/Business Name I UBI Number <br /> C AmPGA i g_I1 �1^S <br /> State of Washington CoNractor License Number: <br /> �. u F_� :� �5� i ���-rr- c,�.A `=i is�\c�, <br /> Vendor Mailing Address City ' State Zip <br /> �-t25 -7_S��i- }%s9� S�r��Ce�J CU�Q�e l ls PI,,�«,h,��ti c��� � <br /> Pfione Email I <br /> i i <br /> I, lhelVendor, agree to receive the Backwater Prevent(on 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 foilowing: <br /> 1.' The Backwater Prevention Devir,e rebate amount will be deducted from the final <br /> invoice given to the Property Owner for the installation at the Prope�ty Address <br /> referenced above, if 1he total cost of the i�stailation is greater than the rebate. <br /> 2. I, ihe Vendor, am a Washington State licensed�contractor. <br /> 3. The City of Fverett will send a Federal Form 1099 MISC to me, the Vendor, for <br /> the I3ack�vater Prevenlion Device rebate payments totaliny more than �600 per <br /> calendar year, and will report the same paymeiits lo lhe Intemal Revenue ! <br /> Service. I <br /> � <br /> I accept ihe direct payment of lhe Backwater Prevention Device rebate from the City <br /> of Fverett pending approval of the completed Qackwater Prevention vevice rebate <br /> package by the �it.v of Fverelt <br /> -- '/ �� <br /> /' � . <br /> II �'_ . _ I : <br /> `-`j--/�-�—� ��'�. -- _ (�C�/ +- ?c�/�� <br /> Sign�tu�oI Contiacfor -r— � <br /> Date <br /> I , <br /> i <br /> ii <br /> I � <br /> Revised�9/3/2014 Page 2iof 2 <br /> i <br />