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Contractor Section: <br />Vendor Name / Business Name! UBI Number <br />/���. ��� .�r <br />State of Washington Contractor License Nwnhec <br />Sc.�%J 'r dT NF .•�.✓YSU;//c Wf% � x'J <br />Vendor h-0ailing Address Cily State Zip <br />�s7���7 — <br />Phone Email <br />I, the Vendor, agree lo receive lhe Backwater Preven�ion Device rebate check directly for lhe <br />inslallation al the above referenced properly address. By agreeing to receive the rebate check <br />directly, I ayree to the following: <br />1. The Backwater Prevention Oevice rebale amount will be deducled from �he final invoice <br />given lo the,property owner for the installation at the properiy address referenced above, if <br />the total cost o( the.installation is greater than ihe rebale. <br />2. I, the Vendor, am a Washington State licensed coniractor. <br />3. The Cily of Everell will send a federal Form 1099 MISC to me, the Vendor, for Backwater <br />Prevention Device rebate payments lotaling more than $600 per calendar year, and will <br />report the same payments to the Internal Revenue Service. <br />1 aocept the paymenl o( tha Backwaler Prevention Device rebale (rom the Cily of Everetl pending <br />approval of the completed Back�vater Prevention Device rebate package by Ihe City of EvereU <br />Signature of Contractor <br />3/ �3f l,.S� <br />Date <br />