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Backwater Preventio� Device <br /> �� Rebate Program <br /> Ven�lor Section (please print): <br /> � — -- -- ----- — <br /> _ _ — - - --- <br /> _ —--- - -- — <br /> C'��„�f�BEt����L�n,F�1�Ur:�,_►r.1c ,_ ' �, u L �iZ.�c� C'�c1.� - -� <br /> Vendor IVame /Business Name/ UHI Number � � <br /> _ � A i�1P('�f� .L C�1�1_!L_��._ <br /> Slate of Washington Contractor License Number. <br /> � <br /> �. L ?i;ti 55`i (_—�v�:'_�i�__ v�-�\ �l �2L�__ I <br /> Vendor Mailcng Address City Sta1e � � <br /> Zi <br /> ��_�� I -_�%$9� SL�'���(C /�cJ<U,^��nj)�-'��� ��v��I),r14 � Cu�a1 I <br /> _ Phone -- --- Email I <br /> I, the Vendor, agree tu receive the Backwater Frevention Device rebate check directly <br /> for ihe installation referenced at the Property Address. f3y agreeing to receive the rebate <br /> check directly, I agree to the follov✓ing: <br /> 1 The Backwater Prevention Device rebate amount v✓ili be deductec� (rom the Final � <br /> �nvoice given to thc Property Owner for the installation at the Property Address <br /> rr�ferenced above, d 1he lotal cost of the installation is greater than the rebate. <br /> 2 I, the Vendor, am a Washinyton State licensed contra�tor. <br /> 3. The City of Everell v✓ill send a 1=ederal Form 109g MISC to me, the Vendor, for <br /> the Backwater Prevention Devir,e rebate payments totaling more than $600 pc�: <br /> calendar year, and will report lhe same payments to thn Internal Revenue <br /> Sernce <br /> I accept the direct payment of the E�ar,k�vater Prevention Device rebate from the Cily <br /> of Fverett pending approval oi th� r.ompleted [3ackwater Prevention Uevice rebate <br /> package by the Cily oF Evere(1 <br /> i <br /> � <br /> --� - - ---- — - - - - -- �ZI ,,_.j <br /> Sigi� lu�r or Ca�trr�r.lor \ '��` - <br /> I�.7fU <br /> Revised 9/3/201�I Page 2 of 2 <br />