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Backwater Prevention Device <br />Reba#e Program <br />Vendor Section (please print�; <br />1-�-L'Vz-b �L-c� � d�3 r w... �-c L(..0 �r D��- `�'Z�— b t(g <br />Vendor Name / Business Name / UBI Number <br />e� .�... .�_ _ _ <br />Sfate of Washington Contractor License Number_ <br />� b3 o x g g 7 .-5' o�o �4--c�•�-L r S t� ��v �4-. 1� 2.S d <br />Vendor Mailing Address Ciiy State Zip � <br />�bC,p -�D � b 9 2`�/ �T,�-�-v�-t- C d(� � � e.r s� Yr�Gl� �, C n.•-- <br />Phone Email <br />I, the Vendor, agree to receive the Backwater Prevention Device rebate check direct[y <br />for ihe instaEfafiion referenced at the Property Address. By agreeing to receive the rebate <br />check directly, I agree to the following: <br />1. The Backwater Preven#ion Device rebate amount will be deducted from the final <br />invoice given #o #he Property �wner for the instailation at the Property Address <br />referanced above, if the total cosfi of the instailation is greater thar� the rebate. <br />2. I, the Vendar, am a Washington Sta#e licensed cantractor. <br />3. The City of Everett wiif send a Federa[ Form 1099 M1SC to me, the Vendor, for <br />the Backwater Prevention Device rebate payments totaiing more than $600 per <br />calendar year, and will report the same payments io the Internal Revenue <br />Service. <br />I accept the direct payment of tf�e Backwater Prevention Device rebate from the City <br />ofi Everett pending approvaE af the completed Backwater Prevenfiion Device rebate <br />package by the City of Everett <br />� <br />� _`� � - � �- ��c <br />Signature of Contracfor <br />Revised 9/3/2014 <br />Dafe <br />Page 2 of 2 <br />