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� <br />� <br />Backwater Prevention Device <br />Rebate Program <br />Vendor Section (pl�ase print): <br />C�f1r�1FE�LL�ti�%LVA1 iV('� �NC_ <br />V�ndor Name I Business Name / U81 Number <br />LAmpGA =_q1� ,.,5 <br />, vZ `121� `��j`� <br />State oF Washington Contractor License Number: <br />, t 6oF `�5�-i i Ev�c-�; �,-� r.i �5?.c��, <br />Vondar Mailiny Address City State <br />_�Z,�j -!�_�I- 5%$�j�] 5L�111 e/�' Z�P <br />C. � cU.��� l ls Pl��,�, h,'�14 .�,•„�, <br />Phone <br />Email <br />I, the,Vendor, agree to receive the Backwater Prevention Device reba�e check directly <br />for the inslallation referenced at the Property Address. By agreeing to receive the rebate <br />cneck directly, I agree to lhe follo�vino� <br />1. The f3ackwater Prevention Device rebate amount will be deducled from the final <br />invcice yiven to the Prooerh� Owner (or the installation at the Properiy Address <br />referenced above, if the total cost of the installation is greater than the rebate. <br />7_. I, the Vendor, am a Washington State licensed contractor. <br />3. The City of Everett will send a Federai Porm 1099 MiSC to me, the Vendor, for <br />lhe Backwater Prevention Uevice rebate payments totaling more than $600 per <br />calendar year, and will report 1he same paS�ments to the Internal Revenue <br />Service. <br />i accept the direct payment of thc B;�r,kwater Prevention Device rebate (rom the City <br />oi Everett pending approval of the completed Back�valer'revention Uevice rebate <br />package by the City�f Everett <br />� <br />o( <br />Revised g/3/2014 <br />_� ��_Z-'�' J <br />Date <br />Page 2 of 2 <br />