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Contractor Section: . <br />Vendor Name ! Busine�s NamE: ! UBI Number <br />��_�I-.r�-.`�-`-��.�— L" - <br />, �; <br />Slate of Washington Contractor Lic?nse Number: <br />��� Lr.�LI�—_Lle,=—�-��LL���,�.ic; �,�. <br />Vendor Mailing Address City State Zip <br />Phone Email <br />I, the Vendor, agree to receive the Back�vater Prevention Device rebale check directly tor the <br />inslalialion at the above referenced properly address. By agreeing to receive the rebate check <br />directly, I agree to the following� <br />t. The Backwater Prevention Device rebate amounl will be deducted irom Ltie final invoice <br />given to lhe properly owncr tor Ihe installation at the property address rcferenced above, if <br />the lolal cost of the installation is grealer than lhe rebate. <br />2. I, lhe Vendor, am a Washington State licensed contractor. <br />3. The City of 6verett will send a Federal Form 1099 MISC lo me, the Vendor, for Backwater <br />Prevention Device rebate payments totaling more lhan $600 per calendar year, and �vill <br />report ihe same paymenis to the Intemal Revenue Service. <br />I accept the payment of the Back�vater Prevenlion Device rebale from thc Ciry of Everett pending <br />approval of Ihe completed 8eckv�aler Prevention Device reb�te package by !he City of Everett <br />�� � � � �;..� _ r� <br />� <br />SignaWre of ContraUor Date <br />