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Contractor Section: <br />Fi��s� l...0 <br />Sn=:.k ,- Se.��r �J —s�Pj�� I ( T <br />Vendor Name ! Business Name I UBI Number <br />/a�JS�Ss � `("� �� <br />State of �Vashington C <br />���� �z���� <br />Vendor Mailing Address <br />-�(�S- G�IR� <br />Phane <br />License Number: <br />5.�% <br />Email <br />City State Zip <br />I, the Vendor, agree to receive Ihe Backwater Prevenlion Device rebate check directly for lhe <br />installation at the above re�erenced property address. By agreeing to receive the rebate check <br />directly, I agree to the following. <br />L The Back�vater Prevention Device rebate amount will be deducted from the finai invoice <br />given to the property ovmer (or lhe installation at lhe property address referenced above, �f <br />the total cost of the mslallaGon is greater than the rebale. <br />2. I, the Vendor, am a VVashington State licensed coniractor. <br />3. The City of Everett �vill send a Federai Form 1099 MISC lo me, the Vendor, for Backwater <br />Prevenlion Device rebate payments tolahng more than $600 per calendar year, and will <br />report the same paymenls lo the Inlernai Revenue Servicc. <br />I accept tlie payment o( the Back�vater Prevention Device rebale (rom the Gty of Everett pending <br />approval of the compieted Backwater Prevention Device rebate package by Ihe City of Everett <br />� . � ,.�-e� - � l - ���.� _ <br />Si naWre o( Contractor Date <br />