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I Backwater Prevention Device <br />" Rebate Program <br />Vendor Section (please print): <br />V to 1 I tJ U L4, L — --- <br />Vendor Name I Business Name I UBI Number <br />State of Washington Contractor License Number: <br />xOkgtt !t Po S- 2 937 SNclkr Sa-- <br />Vendor Mailing Address City state Zip <br />^ �aAk i1 o (I IN�(y� y�Hoa eo <br />2Q(P `I0(P b`iZrr <br />Phone Email <br />I, the Vendor, agree to receive the Backwater Prevention 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 following: <br />1. The Backwater Prevention Device rebate amount will be deducted from the final <br />invoice elven to the Property owner for the installation at the Property Aodrers <br />referenced above, if the total cost of the installation is greater than the reb,ta <br />2. I, the Vendor, am a Washington State licensed contractor. <br />3 he i ty of Everett Backwater Prevention nDev cd a e rebate payments totaling more than $600 -Ieral Form 1099 MISC to 1719. the Vendor, er <br />calendar year, and will report the same payments to the Internal Revenue <br />Service. <br />I accept 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 the City of Everett <br />Signature of Contractor <br />Revised 91312014 <br />ate <br />Page 2 of 2 <br />