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� <br />� <br />Backwater Prevention Device <br />Rebate Program <br />Vendor Section (please print): <br />�'o111PrS�/�OSW��IL /�L�O p�Um6/avLD lo03-�Z.� O!'(� <br />Vendor Name I Business Name / U81 Number <br />l�L� P��S(a3N1 _ _ <br />State of Washinglon Contractor License Number: <br />/� 6oX S�'7 S',..fll�an�ish� wr�, �229v <br />Vendor Mailing Address City State Zip <br />�.00� 4oc� - 0 9 2 9 �„ r�a ��i��s � l�a��oo , ctr�-+ <br />Phone <br />Email <br />I, the Vendor, agree to receive the Backwater PrevenUon 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 C'revention Device rebate amount will be deducted from the final <br />invoi�e given to the Property Owner for the instaliation 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 Oevice rebate payments totaling more than $600 per <br />calendar year, and will rzport the same payments to the Internal Revenue <br />Service. <br />I accept the <br />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 Cily oi Everett <br />Signature o( CoNractor <br />%2 — /U— <br />Date <br />Page 2 of 2 <br />Revised 9/3/2014 <br />