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�ontractor Secfiion: <br />Vendor Name / Busine�s Name / UBf Number <br />,t�1� '�" �� � ��� I � � <br />5tate of Washingion Contrac#or License Number <br />Vendor Maifing Address <br />Phone <br />Email <br />City State Zip <br />I, ihe Vendor, agree to receive the Backwa#er Prevention Device rebate check directly for the <br />ins#aliation at the above referenced property address. By agreeing to receive the rebate check <br />directly, I agree to the fiollowing: <br />1. The 8ackwater Prev�ntion Device rebate amount wilf be deducted from the final invoice <br />given fio the properky owner for the installation af #he property address referenced above, if <br />the total cast of the instafEation is greater than the rebate. <br />2. I, #he Vendor, am a Washington State licensed contractor_ � <br />3. The City of Everett will send a�edera! �orm 1099 MISC ta me, the Vendor, for �ackwater <br />Prevention Device rebate payments totaling more than $600 per calendar year, and will <br />report the same payments to the lnternal Revenue Service. <br />I accept the paymeni of the Backwater Prevention Device rebate #rom the City of Everett pending <br />appro�al of the compfeted Backwater Prevention Device rebate package by the City of Everett <br />� <br />Signature af Contractor <br />l l�_ <br />Date <br />