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Backwater Prevention Device <br />OL Rebate Program <br />Vendor Section (please print): <br />Vendor Name / Business Name / UBI Number <br />LArnpe)p z -, t nS <br />Slate of Washington Contractor License Number: <br />c) , 8"(. 55�41 F VE�CL-17 <br />t,...F\ <br />Vendor Mailing Address City <br />!A25 LS�i- �g�K_ SeryIce J(Lamyb&1i� <br />State <br />Zip <br />Ivolhu''v>� <c&Y\ <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 />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 />I, the Vendor, am a Washington Slate licensed contractor. <br />The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for <br />the Backwater Prevention Device 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 the(-verell <br />of Contractor Date <br />Page 2 of 2 <br />Revised 9/312014 <br />