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�� Bac�cwater Prevention Device <br /> ; Rebate Program <br /> Vendor Section (please �rint): <br /> c���5 w�►►,����, ,, i�. l ce.��u��ay <br /> Vendor Name I Business Nam�a I UBI Number <br /> CA,mP_F�A�c�, 6� rw5 <br /> State of Washington Coniractqr License Number. <br /> _(�.u. �n� 5��{� �✓�21,T1" �,..,A-� �1.8ZvG� <br /> Vendor Mailing Address . ' City State Zip <br /> ��_S-zS� - ,�5��S� ����-o c�.��oy��pw�,l��ro,,, <br /> Phone mail <br /> I, the V�ndor, agree to receive�the Backwater Prevention Device rebate check directly <br /> for the installation referenced �t the Property Address. By agreeing to re�eive the rebate <br /> check directly, I agree to the fo�lowing: <br /> 1. The Backwater Preventipn Device rebate amount will be deducted from the final <br /> invoice given to the I'ruRerty O�roner for the installation at the Property Address <br /> referenced above, if the total cost ef the installation is greater than the rebate. <br /> 2. I, the Vendor, am a Was.hington St��te licensed contractor. <br /> 3. The City oi Everett will send a Fede�sl Form 1099 MISC to me, the Vendor, for <br /> the Backwater Preventiqn Device rebate payments totaling more than $600 per <br /> calendar year, and will rgport the same payments to the Internai Revenue <br /> Service. � <br /> I accept the direct payment o�the eackwater Prevention Device rebate from the City <br /> of Fverett pending approval of the completed Backwater Prevention Device rebate <br /> package b e Cit F Everetl <br /> c�',�l'�. <br /> Si natureolConlractor Date <br /> Revised 9/3I2014 <br /> Page 2 of 2 <br />