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,�� Backwater Prevention Device <br /> � n Rebate Program <br /> Vendor Section (please print): <br /> ��`�n'�F�ELL'S�LUr11 �� �w'C . � �(I U L ��I Z-� �CI l <br /> Vendor Name/[i..siness Name I UBI Numher � <br /> c F,��,n GA .� �� �-� nn s <br /> State o(Washington Contractor License Number: <br /> , l: �ci _`�5`-1 I �v�Z"-�i i" i�r\ �l�S��i <br /> Vendo�Mailing Address City State Zip <br /> i,�Z:� -7 i��i- �%s9� Sc'.fvite�CU�^��b�'IIS Pl��,i�l��vlr , C�,v� <br /> LPhone Email <br /> I, the Vendor, ayree to receive the Backwater Prevention Device rebate check directly <br /> for the installation referenced at the Properly Address. By agreeing to receive the rebale <br /> check directly, I agree to the following: <br /> 1. The Backwater Prevenlion Device rebate amount will be deducted from the finai <br /> invoice given to lhe Property Owner for the instaliation at the Property Address <br /> relerenced above, if the lotal cost of the installation is yreater than the rebate. <br /> 2. I, ihe Vendor, am a Washinyton Slate licensed contractor. <br /> 3. The City of[verett 4vill send a Pederal Form 1099 AqISC lo me, the Vendor, (or <br /> the E3acicwater Prevention Device rebate payments lotaling more than $600 per <br /> calendar year, and will report lhe same payments to the Intemal Revenue <br /> SCNICC. <br /> I accept the direct payment o(the Ciackwater Prevention Device ret�ate from ihe City <br /> ot L=veretl pending approval of the completed Backwater Prevention Device rebale <br /> packa�e by the�iLy.�f Everett <br /> .-- / r <br /> •�" � ' <br /> �� �.. _�'I'_ "i,�� _ _.. � -- , i��� _ <br /> � ;� <br /> Signattu_5 al Contrar.tor Date <br /> Revised 913/201�i Page 2 of 2 <br />