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�� <br />Ba�kwater �revention Devic� <br />Rebaie P�ogra�m <br />Vendor Section (please print): <br />_C}��,�FgEu,S _ �. �a� ��r- _I���a�'� `1�1� C�(�('.� <br />Vendor Name ! f3usiness Name / UBI Number <br />C A rnP Gl� ��t �-��n�— -- --- - <br />State of W�±ashington Conlractor License Number: <br />, L� . U��_�� J�--� L� vrr-Qc_il_ (�-�r� `� i$ �t�; — <br />Vendor Mailing Address Cily State Zip <br />� - ���sa - <br />�-t ZS - Z5� i F, `� �r�� i CN �U CU,Mt�b� 115 l v<<, h�',�y , ��:�n <br />--� - ---�— <br />Phone Finail <br />I, the Vendor, ayree tn rer,eive the Backwater Prevention Device rebate check directly <br />for the installation referenced at the Property Address. By agreeing to receive the rebate <br />check directly, I agree lo the foilowing: <br />The E3ackwater Prevention Uevice rebate amouni will be deducted from the final <br />invoice given to the Property Oumer for the installation at the Property Address <br />referenced above, if the totai cost of the installation is grealer than the rebate. <br />I, the Vendor, am a VJashington State iicensed contractor. <br />The City of Everett will send a f=ederal Form 1099 MISC to me, the Vendor, for <br />the Backwater Prevention Device rebate payments totaling more than $600 per <br />r,alendar year, and �vill repoR thu sarne payments to the Iniemal Revenue <br />Servi�e. <br />I accept the direcl payment o( lhe [3ar.k�water Prevention Device rebate from the City <br />of Everett pending approval of the rompleted Backwater Prevention Device rebate <br />package by the Gii�yf Everett <br />o! Contracror <br />Revised 9I3/2014 <br />Dafe <br />I'age 2 of 2 <br />