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Backwater Prevention Device <br />�'r Rebate Program <br />Vendor Section (please print): <br />n1Pil���LU11 IIiL_�rJL UZ �12� IC1 1 _• <br />Vendor Name I Business Name 1 UBI Number <br />L1-\rl)pBP'=(at111AS --- — <br />Stale of Washington Contractor License Number: <br />F L But. 513H i I=y ZL-,7 Ls IA `i S 2 Ap <br />Vendor Mailing Addross City State Zip <br />5-7�ri 89;5 service (&"l <br />Phone Email <br />I, the Vendor, agree to receive the Bankwater Prevention Device rebate check directly <br />for the installation referenced z t the P, ')perty Address. By agreeing to receive the rebate <br />check directly, I agree to the following: <br />1. The Backwater Prevention Device rebate amount will be deducted from the final <br />invoice given to the Property Owner for the installation at the Property Address <br />referenced 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 MISC to me, the Vendor, for <br />the Backwater Prevention Devine rebate payments totaling more than $600 per <br />calendar year, and will report the same payments to the Internal Revenue <br />Service. <br />I accept the direct payment of the Backwater Prevention Device rebate from the City <br />of Everett pending approval of the completed Backwater Prevention Device rebate <br />package by tfleityy-9f Everett <br />of Contractor <br />Revised 9/3/2014 <br />Date <br />Page 2 of 2 <br />