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� <br />Backwater Preventior_ Device <br />Rebate Program <br />Vendor Section (please print): <br />_� �TZv {�L �, M/� r..� u � c., c ('s o�i - 42-5�— n 1(a <br />Vendor Name / Business Name / UBI Number <br />_ N ewo �r� p_ r�.: �. N►- <br />Stale oi Vt�ashington Contractor License Number. <br />� �r�x �nZ S�oUnn. iSN a-K� `7'�i'2i� <br />Vr�en�dor Mailing l�ddress City Sta/te� Z�p <br />1-UiJ'-T[JiP' � l Z�% �Y'C'-1 r�o1(r��rS ��i./ yl�f=OJ . Cr7e•^ <br />.�� <br />Phone Email <br />i, the Vendor, agree ?o receive the Backwater Prevention Device rebate check c�rectly <br />for the installation referenc2d 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 tot�� cost o( the installation is greater tnan the rebate. <br />2. I, the Vendor, am a Washington 5late licensed contractor. <br />3. The City of Everett wili send a Federal Form 1099 MISC to me, the Vendor, for <br />the Back��;ater Prevention Device rebate payments totaling more than 5600 per <br />calendar year, and will report the same payments to the Internai Revenue <br />Service. <br />I accept the d:rect payment of the Backwater Prevention Device rebate from the City <br />of Everett pending approval of the compleled Backwater Prevention Device rebate <br />package by the City of Everett <br />G <br />Signature of Contnctor <br />P.evised 9/312014 <br />Date <br />z9--�s <br />Pag= 2 0( 2 <br />