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Contractor Section: <br />�/e.�dor Name I <br />Name! UBI Number <br />_gl_'t-�FlZ�7 � `�j trzl-�-1- <br />State of Washinglon Contractor License Number <br />Vendor Ivlailing Address <br />Phone <br />Email <br />Gity State ZiP <br />I, Ihe Vendor, agree to receive the �ackvaater Prevention Device rebate check direcUy for Ihe <br />insiallation at the above referenced properly address. By agreeing to recei�,e the rebate check <br />directly, I agree to the following: <br />1. The Back�vater Prevention Device rebate amount �vill be deducted from the final invoice <br />given to the property oamer for the installalion at the property address re.ferenced above, if <br />lhe lolal cost of the installation is greater Ihan the rebate. <br />2, I, Ihe Vendor, am a Washington State licensed contractor. <br />3. The City oi [verett mill send a Federal Form 1099 tv11SC to me, ihe Vendor, for B�r,k�vater <br />Prevention Device rebate paymenls tolaling more than 5600 per calendar year, and will <br />report the samc paymenis to lhe Intemal Revenue Service. <br />I accepl the p�Ymenl of the Dackv✓ater Prevention nevice rebale irom the Ciry of [verett pending <br />approval ot the compleled Backwaler Frevention Device rebate package by the Ciry of Everolt <br />� <br />�d _ — �_'��� -- --�a I I-�- ---- <br />Signalure oi Contractor Date <br />