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Contractor Section: <br />/�u�n <br />Vendor Name / Business N�me I UBI Number <br />i �av� ��-�; S'�' 7 �' U — <br />State of Washington Contracror License Number: <br />I�Si S�(�S'l� S� S�e��,w'�� c�.Jr `�3�z�ro <br />Vendor Mailing Address Cily State Zip <br />�� S 7�c; 5 �Gz� ����J,'Jt., ,�'4,.,1,:-y � �..—_'-_ <br />Phone Email <br />I, the Vendor, agree to receive the Back�valer Prevenlion Device rebate check directly for tha <br />installation at the above referenced property address. By agreeing to receive the rebate check <br />directly, I agree to the following: <br />1. The Back�vater Prevention Device rebate amount will be deducted from ihe hnal mvoice <br />given lo the property owner for the installation at the property address referenced above, i( <br />the tolal cost of the installation is grealer lhan lhe rebate. <br />2. I, lhe Vendor, am a UVashington State licensed conlractor. <br />3. The Cily of Everett �vill send a Federal Form 1099 MISC to me, Oie Vendor, for Backv�ater <br />Prevention Device rebate payments totaling more than 5600 per calendar year, and will <br />report the same payments to the Internal Revenue Service. <br />I accepl the payment ol lhe Backwaler Prevenlion Device rebate from the Ci�y oi Everetl pending <br />approval of the completed Back�valer Prevention,Device rebate package by the City of Everett <br />Signature of Contractor <br />3—�s _,c' <br />Date <br />