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Backwater Prevention Device <br /> vrgi Rebate Program <br /> Vendor Section (please print): <br /> et\i'abEW Cf2- 97-SD 9'6 <br /> Vendor Name/Business Name// UBI Number <br /> iftIPSP <br /> State of Washington(� Contractor License Number: <br /> ('s . i3 . 55H E v & r-ir Cl <br /> Vendor Mailing Address <br /> City State <br /> LZ`a -75cc- S`,}5`1i S V1( c0cAm I�S �1U1 E1Zip <br /> Phone Email <br /> I, the Vendor, agree to receive 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 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 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 1 009 MISC to me, the Vendor, for <br /> the Backwater Prevention 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 of the Backwater Prevention Device rebate from the City <br /> of Everett pending approval of the completed Backwater Prevention Device rebate <br /> package by the ' f Everett <br /> 411111,"4110.o <br /> Signet of Contractor Date <br /> Revised 9/3/2014 Page 2 of 2 <br />