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� <br />� <br />Backwater Prevention Device <br />Rebate Program <br />Vendor Section (please print): <br />�-i�"RD �� c, w� f3 r ti•�a l L C <br />f+lame / Business Name 1 UBI Number <br />c�PPl. f•'>in'S � L <br />State of Washinyton Contractor License Number: <br />Rh f?��X S":�7;7 St�oHon��S� �,�.�a. i�i'29/ <br />Vendor Mailing Address Cily State . Zip <br />�.�1(��- �7.7(O— O�I'2.`/' �TGC�••T C'GGile..�S' �c� �/:�1Knn �!_[aR-� <br />Phone Email <br />� <br />I, !he Vendor, agree to receive the Backwater Prevention Device rebate check directiy <br />for the installation referenced at the Property Address. By agreeing to receive the rebate <br />chack directly, I agree to the following: <br />1. The Backwater Prevention Device reh<�te amount will be deducted from the final <br />invoice given to the Property Owner for the installation at the Property Address <br />re(erenced above, if the total cost of the installation is greater than the rebate. <br />2. I, the Vendor, am a Washington State iicensed contractor. <br />3. The City of Evere[t will send a Federal Form 1099 MISC to me, Ihe Vendor, for <br />the Backwater Prevention Device rebate payments totaling more than $600 per <br />calendar year, and wili repoR the same� payments to the Internal Revenue <br />Service. <br />I a�cept the direct payment of the Backwater Prevention Device rebate from the City <br />of Everett pending approval o( tlie completed Back�vater Preven(ion Device rebate <br />package by the City ot Everett <br />��`'' ,---- <br />Signature of Contrar,tnr <br />� - ��� --�� <br />Date <br />Page 2 of 2 <br />Revised 9/3/2014 <br />