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Backwater Prevention Device <br />Rebate Program <br />Vendor Section (please print): <br />(I,o` <br />Vendor Name / Business Name I UBI Number <br />(-Ar)PGP i 0I1-1 I� <br />State of Washington Contractor License Number: <br />I<ViEL-17 <br />t,• A <br />`i `s2L�c�. <br />Vendor Mailing Address City <br />5e--rV-1 C ¢i (16 mobe <br />State <br />15 <br />Zip <br />Plvm h,'vty Cuen <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 />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 $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_SitMf Everett <br />of Conhactor <br />Revised 91312014 <br />Date <br />-z.(41-r <br />Page 2 of 2 <br />