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Contractor Section, <br /> Vendor Name!Business ame 1 UBI'Number <br /> State of Adashington Contractor License Number_ <br /> - , ar <br /> Vendor Mailing Address City State Zip <br /> LYS— 4f <br /> Phone Email <br /> :r ✓wu'>.:::�vf f .U`Yt"aiacoa L aviice rebate Check directlyfor the <br /> installation at the above referenced property address. By agreeing to receive the rebate check <br /> directly, I agree to the following: <br /> 1. The Backwater Prevention Device rebate amount will b:: uhcv lit iai irlvc o4ti: <br /> given to the property owner for the installation at the property address referenced above, if <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 1099 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 /> o 4 <br /> Si Contractor Date <br />