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Contractor Section: <br />Vendor Name ! Busine�s Name / UBI Number <br />q�� � <� br��I K� — <br />State of Washington Contractor License Num6er: <br />Vendor Mailing Address City State Z�P <br />Phone Email <br />I, the Vendor, agree lo receive the Backwaler Prevention Device rebate check directly for the <br />installation at the above referenced prope�ty address. By agreeing to receive the rebate check <br />directly, i agree to the following� <br />1. The Backwater Prevention Device rebate amount will be deducted from the final invoice <br />given to the property owner for lhe installation at the property address referenced above, if <br />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 Everect will send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br />Prevention Device rebate payments lotaling more than 5600 per calendar year, and will <br />report the same payments to the Internal Revenue Service. <br />I accept the payment of the Backwater Prevenlion Device rebate from tlie City of Everett pending <br />approval of the completed 8ackwater Prevention Device rebate packape by the Ci[y of Everett <br />���_. �� ��� _ <br />Signature of Contractor <br />Date <br />