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1 <br /> ii <br /> Contractor Section: <br /> A SO <br /> Vendor Name I Busine�NameNumber <br /> 1Stat - s 5 s K1- <br /> State <br /> e of Washington Contractor License Number: <br /> S <br /> Vendor Mailing Address City State Zip F <br /> 'tri: r_ , � ,ice¢�� r�-z <br /> 5 <br /> Phone Email <br /> 3 <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, 1 agree to the following: <br /> t <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 t <br /> the total cost of the installation is greater than the rebate. <br /> 2. I, the Vendor, am a Washington State licensed contractor. <br /> 3. The City of Everett will send a Federal Form 10gg 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 /> :p <br /> Date <br /> Signature of Contractor <br /> F. <br /> 4 <br /> t <br /> r <br />