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Backwater Prevention D�Gvice <br />Ret�ate Program <br />Vendor Section (please print): <br />Ir.-t-� �'o!/���s yE.� P�✓mFSrN�.% �o�-4-ZS- n�(o _ <br />Vendor Name / Business Name I UBI Number <br />NE¢vPPL66s�1 <br />of Washington Contractor License Number: <br />p�(� �Y?X ��� SNf . n•tSc+- t•:� , q� L� � <br />Vendor A4ailing Address City State Zip <br />�CiC`����1 "ifl`Zl TrptiTC'n1112�r�q{.JOn �Cc'Y'" <br />Phone <br />Email <br />I, the Vendor, agree to receive the Backwaier Preven:ion 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 Back.water Prevention Device rebate amount �vill 6e deducted from the final <br />invoice given tc� the Property Ovmer for the installation at ihe Property Address <br />referenced abo�e, if the total cost of the installation is gmater than the rebate. <br />I, the Vendor, am a Washington 5tate licensed contractor. <br />The City of Everett will send a Federal Form 1099 MISC to me, the Vendor, for <br />the Back�vater Prevention Device rebate payments totaling more than $600 per <br />calendar year, and will report the same payments to lhe Intemal Re��enue <br />Service. <br />I accept the direct payment of the BackNater Prevention Device rebate from the City <br />of Everett pending approval of the compieted Backwater Prevention Device rebate <br />package by the City of Everett <br />Signature of Contracfor <br />Revised 9/3120i4 <br />Y�-- r s <br />Date <br />Page 2 of 2 <br />