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Contractor Section: <br />Vendor Name 1 f3usine�s Name / UEiI Number <br />Art�.� ��-K��- - <br />State of `Nashingion Coniractor License Number: <br />Vendor Mailing Address Clry State Z�P <br />Phonc Email <br />I, the Vendor, og'�e to receive the Back�vater Prevenlion Device rebate r.heck directly }or the <br />inslallation at the a6ove referenced property address. By agreeiny tu rece.�e lhe rebale check <br />directty, I agree to the following� <br />1 The Backw.ater Prevention Device rebale amount will be deducted from ihe finai invoice <br />given to lhe property owner for the installation at Ihe property address referenced above, if <br />lhe total cost of lhe installation is greater than Ihe rebate. <br />2. I, lhe Vendor, am a Washington Stale licensed conlracinr. <br />3. The City of Evcrett will send a Federal Form 1099 MISC to me. Ihe Vendor, for Backv�aler <br />Prevention Device rebate paymenls totaling more than 5600 per calendar yoar, and will <br />report lhe sarne paymeNs to the Internal Revenue Service <br />I accept tt,e payment o( the Backv+ater Prevention Dovice rebate from the City of [verell pending <br />approval of the completed Dackwater PrevenUon Device rebale package by the Glty oi Fverett <br />l�G�•U.�-� ��.C-_.� -- � 1.�1� <br />Signalure of Contractor Dale <br />