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I <br /> i <br /> 4,e...„ <br /> Backwater Prevention Device <br /> Rebate Program <br /> Vendor Section (please print): <br /> L,,Lv,,P .'3 PLv rim 6 lry h1 l 1\3c , c`2- Cif 2k) CI Ck4 <br /> Vendor Name/ Business Name/ UBI Number <br /> AMPCi) -.qI—I IV1S <br /> State of Washington Contractor License Number: <br /> ._........... <br /> Vendor Mailing Address Cit State <br /> Y Zip <br /> f-tZ5 .-25ci- s`WS' 5er4`ICS0 (c\mpbe lb--pik,vibt'Aff <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 /> tactor. <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 /> 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 City of.Everett <br /> lir , 411 1 1S1 fic--- <br /> Signa ure of Contractor Date <br /> Revised 9/3/2014 Page 2 of 2 <br /> 1 <br />