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Contractor 8ection: <br />Vendor Plame I Busine�s Name I UBI Number <br />�t_I����h; M� — <br />State of Washington Contraclor License Number: <br />Vendor fv1ailing Address City State Zip <br />Phone Email <br />I, fhe Vendor, agree to receive the Backwater Prevenlion Device rebate check directly for the <br />installation at the above referenced pro�erty address. By agreeing to receive the rebale check <br />directly, ! agree to the'allowing� <br />1. The Backwaler Prevention Device rebzte amount will be deducted irom the final invoice <br />given to the property owner for the installa:ion at the property address referenced above, if <br />the total cost of the installa�ion is greater lhan lhe rebale. <br />2. I, the Vendor, am a Washington State Iicensed contractor. <br />3. The City of Evere�t lvill send a Federal Form 1099 MISC to me, the Vendor, for Backwater <br />Prevention Device rebate pay�ments totaling more than $E00 per calendar yaar, and will <br />report the same paymenls to the Intemal Revenue Service. <br />I accepl the paymen[ of lhe Backwaler Prevention Device rebate from the City of Everett pending <br />approval of the completed Backwater Prevenlion Device rebale package by the Gity of Everett <br />C�' ��___ ���� ��j` ��� <br />SignaWre of Contractor Date <br />