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� BaCkwater Prevention Device <br /> Rebate Program <br /> Vendor Section (please print): <br /> G�,�� �PW N . �¢oZ �Z.� � <br /> Vendor Name/Business Name/UBI Number <br /> C.4k,r�-P�RP.� C�i'1 ��'► .5 <br /> St of Wasp�'ng!on Contrecfor License Number: <br /> �. 0 � lSc� SS�a iEu�01r� w'►4---- �1 $?.6(0 <br /> �Ve dor Mailing Addross City State Zip <br /> �FiG- `��j� SG�'V�lC'— �('QT ��5, -���J�.(� ti <br /> Phone Email <br /> I, the Vendor, agree to receive the Bar.kwater Prevention Device rebate check directly <br /> for the installation referenced at the Property Address. By agreeing to recelve the rebate <br /> check directiy, I agree to the followfng: <br /> 1. The Backwater Prevontion Device rebate amount will be deducted from the final <br /> im•oice given to the Property Owner for the installation at tho Property P,ddress <br /> referenced above, if the total cost of the installation is greater than the.rebate, <br /> 2. I, the Vendor, am a Washfngton State licensed contractor. <br /> 3. The City o(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, a.id will report the same payments to the Internal Revenue <br /> Service. <br /> I accept the d(rect paymenl of the Backwater Prevention Device rebate from the City <br /> of Everett pending approval �;f the completed Backwator Prevention Device rebate <br /> packege by the of Everett <br /> � .. , <br /> Signatu f Confractor Date <br /> Reviced 9/3/2L'�4 Pege 2 of 2 <br />