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��, <br />Backwater Prevention Device <br />Ret�ate Program <br />Vendor Sectio� (piease print): <br />1� a2c� PL� w• i3 i r� c� �-�.-c . <br />VGndor Name I Buslness_Name / UBI Number <br />of Washington Contractor License Number: <br />Vendor Mailing �ddress City State Zip <br />�P(i`�D�P - O`7 'L`) -�-�t-r�; Cbl1iP:S����/1L'v Cn..-� <br />Phone <br />Email <br />I, the Vendor, agree to receive the Backwater Prevention �evice rebate check dire�tly <br />for the installation referenced at the Property Address. 8y agreeing to receive the rebate <br />check directly, I agree to the following: <br />1. The Backwa+er Prevention Device rebate amount will be deducted from the fin2i <br />invoice aiven to the Property Owner for the installation at the Property Address <br />referenced abnve, if the total 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 1099 MISC to me, the Vendor, for <br />the Backwater Prevention Device rebate payments totaling more than �600 per <br />c2lendar year, and will report the same payments to the Internal Revenue <br />Service. <br />I accept the direct peyment of the Sackwater Prevention Device rebate irom the Cily <br />oi Everett pending approval oi the completed Bacicwater Prevention Device rebate <br />package by the City of Everett <br />Signature ul Contractor <br />Revised 973!2014 <br />� -,29 - is <br />Date <br />Paae 2 o( 2 <br />