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Contractor Section: <br />Vendor Name I Busine�s Narne J UBI Number <br />�`�_��:.T��-�-� � � --- <br />State of Washington Contractor License Number: <br />Vendor Mailing Address <br />Phone <br />Email <br />City State Zip <br />I, the Vendor, agree to receive the Backwater Prevention Device !Pbale check directly for the <br />inslallation at Ihe above referenced property address. By agreeirg to ;eceive fhe rebale check <br />directly, I agree lo the followinn� <br />1. The Backwater Prevention Device rebate amount will be deducted from lhe final invoice <br />given to the property ovrner for the installation at the property address reFerenced above, if <br />lhe total cost of the instailation is greater than the rnhate. <br />2. I, the Vendor, am a Washington Slate licensed contractor. <br />3. The City of Everett r�ill send a Federal Form 1099 MISC lo me, lhe Vendor, for Backwater <br />Preventio� Device rebate paymeNs totaling more than 5600 per calendar year, and will <br />report lhe same payments lo the Inlernal Revenue Service. <br />I accepl the payment oi lhe Backwaler Prevention Device rebate (rom Ihe City of F_verett pending <br />auprovai o( the completed Backwater PreveNion Device rebate package by the City of Everett <br />Signalure of Gonlractor <br />—�/_���s <br />Date <br />