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Contractor Section: <br />Vendor Name / Business Namia / UBI Number <br />State of Washington Contractor License Number: <br />i/j-(C IY <br />Vendor Mailing Address City State Zip <br />Phone 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 installation 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 ing MISC to me, the Vendor, for Backwater <br />prevention Device rebate payments totaling more than $600 per calendar year, and will <br />report the same payments to the Internal Revenue Service. <br />I 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 />1�G�4 O Q, ��_✓ _. <br />Signature of Contractor Dale <br />