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Backwater P'revention Device <br /> Rebate Program <br /> Vendor Section (piease print): <br /> 44�w Pl.v..�� �,.•c� u.� f�o3 - 42s- �i� <br /> Vendor Name I Business Name /UBI N�mber <br /> _ 1��^�oPPI- g(n 31� 1 ' <br /> State of 1���ashington Contraclor License Number. <br /> �7 �b-x 4��8-7 sNo�,ov,-.� s �-t- �..�� . 9� 2, / <br /> �V]e,�n�dor�M/a,i�ling Addqressq Ciry State i Zip <br /> OwIP-�l/�O_^� l Z / '�V'N.�l'�-Ct��'��C'rS �l yIQ-�'�'00 " �/1'1 <br /> Phone Email <br /> I, lhe Vendor, agree to receive the Backwater Prevention Device rebate check directly <br /> for the installation refeienced at the Property Address. By agreeing to receive the rebate <br /> check dire�tly, I agree to the tollowing: <br /> 1. The Backv✓aier Prevention Device rebate amount will 6e deducted from the final <br /> invoice given to the Property Ov:ner for the installation at the Property Address <br /> referenced above, if the lotal 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 9099 MISC to me, the Vendor, for <br /> the Backwater Prevenlion 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 o(the Backwater Prevention Devi�e rebate irom the City <br /> of Everett pendinc� approval oF the completed Backwater Prevention Device rebate <br /> package by ihe City of Evereli <br /> 5 � I ,� <br /> Signa(ure of Contractor Date <br /> Paae 2 ot 2 <br /> Revised 9/3i2014 <br />