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���tg6�acCgr sec@ior�: <br />j'�ui�n I��vtr�+��itli�/ C:L� <br />Vendor Narne ! Business Nartfe / UB� Number <br />�v� 4i �' /1 �! :f <f $S i 1 i ) <br />State of Washington Contractor Licenso Number: <br />I 7S � 5 �I I'—'� S(- �E S,'1 �o,^-�� Sl. �✓�E �/Y7_�) U <br />Ve�dor Mailing Address Ciq� State Zip <br />W�S•%&U��L.O ?rt.��LJ �l�i:,L'��I�.,,-+J��r��/.c�,�h <br />Phone Email <br />I, ihe Vendor, agree to receive the Bacicveater Prevention Device rebate checic directly for ihe <br />installation at the above referenced property address: 8y agreeing to receive the rebato check <br />directiy, l agree to tiie following: <br />1. The BaGavaler PrevenYion Device rebate amount wili be deducted from the final invofce <br />given to the properry owner for the installation at the propedy address referenced above, if <br />the total cosl oi the instailalion is greater then the rebata. <br />2. I, lhe Vendor, am a Washington Slate Il�ensed coniraelor. <br />3. The Cily of [verett will send a Federal Form 1 Q99 MISC to me, the Vendor, for BackLvater <br />Prevention Device rebate payments tolaling more lhan $600 per r.aiendar year, and will <br />reUort the same payments lo lhe intemal Revenue Service. <br />I accept lhe payment of the Back�,valer Prevention Device rebate from the Clty of Everett pending <br />apry�oval of Ihe complcled Bar.kwalcr Prevention Dovice �ebate packoge by iho Cily of Everelt <br />` d�-cr.✓� . '�� %�7-'�c:�--- (� — I � - � Sr <br />Signaluro of Contractor Date <br />