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Backwater Prevention Device <br />Rebate Pnogram <br />Vendor Seciion (please print): <br />(' �,�F6FU.'S �L.��11F�pL'•(-� Ii�'CL <br />Vendor Name / Business Name 1 UBI Numher <br />_LF,mPGA a_ �1�-1 i1nS <br />D Z �1Z1� 1�1`� <br />State of W�+ashing�on Contrar,(or License Number: <br />�, t:. 1_7(iti r��.>`'� ( �V'�.`^_17 �r..r'� r� t)��.i <br />Vendor Mailiny Address City State Zip <br />�,_ZS��i - �`'�s9� Scrv ��e J �U��, i � <br />n�clls� �I�,,:,h.',,� .,..,.�„ <br />Pnone <br />[mail <br />I, lhe Vendor, agree to receive the Backwater Prevention Device rebate r,heck directly <br />for ;he in�atallation re(erenced at the Property Addressj By agreeing to receive the rebate <br />check directly, I agree to tlia following: <br />1. The Ciack�vater Prevention Device rebate amount will be deducted from lhe fnal <br />invoice gi��en to the Property O�vner (or the inst�llation at the PropeRy Address <br />reterenced above, if the total cosf o( the installation is greater than the rebate. <br />Z. I, the Vendor, am a L"�ashington State licensed contractor. <br />3. 'I"he City of [verett vdill send a Federal Form 1099 MISC to me, the Vendor, for <br />the Backv�aler Prevention Uevice rebate payments totalirg 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 o( the (�ackwater Preventiori Device rebate from the Ciry <br />of L=verelt pending approval of the completed f3ack�vater Preventinn Device rebate <br />package by the Cit�f Fverett <br />-t �� ��1---- <br />Dare <br />Revised �!3(.2014 Pa�e 2 oi 2 <br />