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Contractor Section: <br />Mpcn <br />Vendor Name! Busines Name I UBI Number <br />--- <br />State of Washington Contractor License Number: <br />Vendor Mailing Address <br />N2 S -26d 8-3Gv <br />City <br />State Zip <br />cow -- <br />Phone <br />Email <br />I, the Vendor, agree to receive the Backwater Prevention Device rebate check directly for the <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 Backwater Prevention Device rebate amount will be deducted from the final invoice <br />given to the property owner for the inslallation.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 Stale licensed contractor. <br />3. The City of Everett will send a Federal Form 1099 MISC In me, the Vendor, for Backwater <br />Prevention Device rebate payments totaling more than $500 per calendar year, and will <br />report the same payments to the Internal Revenue Service. <br />accept the payment of the Backwater Prevention Device rebate from the City of Everett pending <br />approval of the completed Backwater Prevention Device rebate package by the City of Everett <br />�—-- 2 — (7— rss <br />Signature of Contractor Date <br />