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Backwater Prevention Device <br />00 7 Rebate Program <br />Vendor Section (please print): <br />_µG�w PLUMf3twf <br />CLC (0a'(t, <br />Vendor Name / Business Name / UBI Number <br />'C RG' '? a <br />yate of Washington Contractor License Number: <br />b &nx 6M z-ro4-0jY1I SN wrs , is Z-7o <br />Vendor Mailing Address <br />.1b to- '('f7(P- OI2`j <br />City Slate Zip <br />'Trnn7'rol�ll�'VS� Y«91'b0 ,Grin'\ <br />Phone <br />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 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 Device rebate payments totaling more than S600 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 City of Everett <br />• 3�2 n t 5— <br />Signature of Contractor Date <br />Page 2 of 2 <br />Revised 9/312014 <br />