HomeMy WebLinkAboutMIFAB_APP_W9.pdfSMALL BUSINESS ASSISTANCE GRANT APPLICATloN
Complete the fillable application in /ts enti+edy. Print the completed application,
sign and date and email, along with a copy of your W-9, to: OED2@auburnwa.gov.
Applications can also be mailed to the following:
CityofAuburn
Attn: Office of Economic Development
25 W Main
Auburn, WA 98001
TO BE COMPLETED BY APPLICANT
Name of Business: Miller Fabrication lnc.
Name of Business Owner(s):Janeil Hard
Business Address: 1435 R St. MW
City of Auburn Business License number: BUS-02444
Expiration Date of Business License: 12/31/2020
Contact Person Name and Title: Janeil Hardy President
Contact person E-mail: jrhardy@millerfab.com
Contact Person Phone: 25_3_I_833-5400
(Optional) Is this business 519/a minority-owned or women-owned (Y/N)
Please initial each to confirm:
|]|_ 10 or fewer employees
]jL A for profit business in the City of Auburn established prior to January 1, 2020
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|||. Business has a physical presence (address) located within a commercial zone
within the City of Auburn. (Home based businesses do not qualify).
JET Business was adversely impacted by mandatory and/or voluntary business
closures directly related to the public health response related to COVID-19
.||L Business in good standing (including: current City of Auburn business license;
current on all State and regulatory requirements; not facing pending litigation or
legal action, including Shoreline code enforcement)
By my signature below,I have read and understand the Small Business Assistance
Grant Program. I make the following representations and acknowledge agreement to
the following terms and conditions:
• The Grantee shall comply with all applicable federal, state, and local non-
discrimination laws and/or policies, including, but not limited to, the Americans
with Disabilities Act, the Civil Rights Act, and the Age Discrimination Act.
• The Grantee affirms that residents, customers and/or employees are not
discriminated against due to race, creed, color, religion, sex, national origin, or
disability.
• ln the event of the Grantee's noncompliance or refusal to comply with any non-
discrimination law or policy, this Agreement may be rescinded, cancelled, or
terminated in whole or in part, and the Grantee may be declared ineligible for
further agreements with the City.
• ln no event shall the City's financial responsibility exceed the approved amount,
set forth below.
• The Grantee is responsible for any and all costs or liability arising from the
Grantee's failure to so comply with applicable law.
• I bearfull responsibility and understand thatthe Grant funds may betaxable
income; please consult with your financial advisor for guidance. A 1099 will be
issued to all grant recipients, as required by the IRS, no later than January 31,
2021.
• There is no agency, employment, joint venture or other such relationship
created by virtue of award of the grant. The City does not endorse the specific
business.
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• Applicant shall defend and indemnify the City and its employees from and against
any claim, injury, liability, loss, cost and/or expense or damage including all costs
and reasonable attorney's fees, arising from or alleged to arise from the activity
or event.
• The representations made by applicant in this Application are material terms of
the Agreement, as is compliance with Small Business Assistance Grant Program.
The City may cancel this Agreement at any time upon discovery that any of the
information set forth above is inaccurate, that these terms have been violated,
or any provision of the Small Business Assistance Grant Program has been
violated.
• Upon approval of this application, as evidenced bythe signature of the City
Representative below, this application becomes a binding contract between the
entity named above and the City of Auburn (Agreement).
• I am the duly authorized representative of the entity named above and can bind
the entity to the terms of this Agreement.
• I attest that the grant funds will be used to reimburse the costs of business
interruption caused by mandated or voluntary closures directly related to public
health directives associated with COVID-19. These funds are specifically for
COVID related impacts and needed to mitigate financial damages to your
business.
• I have Provided a current IRS W-9 with my signed application
Applicant Signature:
By signing this document, I
the debarment or
Date:___z6~c2_3_'±422C)
exists that is likely to result in
suspension of the business from contracting with the U.S. Government or any agency or
instrumentality thereof, and the business is not now and has not been subject to any such debarment or
suspension.
TO BE COMPLETED BY CITY STAFF
Grant Application Granted? Yes I No I
If no, provide reason
lf no, has notification
Grant Payment Date:
City Representative S
for denial:
been sent to applicant?Yes H No H
ignature:Date:
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X
7/7/2020
F.rm W-9
(f]ov. October 2018)
%#rtalm£;e°nfut:esT#cS®ury
Request for Taxpayer
Identification Number and Certification
> Go to www./rs.gov/For7rm® foi. instructions and the latest information.
1 Name (as shown on your Income tar rctum).
Miller Fabrication lNC.
Give Form to the
requester. Do not
send to the lRS.
Name ls requlred on thls lino: do not loavo thls line blanl(.
2 Business mane/disregarded entity name, if d.rfferent from above
3 Check appropriate box tor federal tax classmcation Of the porcon whoso name is entered on lino 1. Chcok only oiie of the
following seven boxes.
H Individual/soleproprietoror I Ccorporation PI Scorporation H partnershlp I Trust/estate
single-member LLC
I Limited liabllfty company. Enter the tax classification (C=C corporatlon, S=S corporation, P3Partnershjp) + -
Note: Check the appropriate box ln the llne above for the tax classmcatlon Of the slngl®-member owner. Do not clieck
LLC if the LLC is classltled as a single-member LLC that ls disregarded trom the o`^rner unless the owner Of the LLC ls
another LLC tnat ls not disregarded from the owner for U.S. toderal ten purposes. Othowlse, a slngle-member LLC that
is dlsregarded from the owner should check the appropriate box for the tax classfficatlon of its owner,
I Other (see Instructions) >
6 Address (number, street, and apt. or sulte no.) See Instructions.
1435 R Street NW
4 Exemptions (codes apply only to
certain ontlties, not lndMduals; see
instructions on page 3):
Exempt payee code ¢t any)
Exemption from FATCA reporting
code ¢f ar`y)
u\pptos lo 8Gcoui*s meinlair\cd o¢nsldo tr\c u.S)
Requester's name and address (optional)
6 Clty, state, and ZIP code
Auburn, WA. 98001
7 LJst account number(a) here (optlonal)
er Identification Nilmber ITIN)
Enter your TIN
backup withholding. For indlvidu8ls, this ls generally your social security numbe-r (SSN). However, for a
resident alien, sole proprietor, or disregarded entity. see the Instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN' later.
Note: If the account is ln more than one name, see the instructions for line i. Also see What Ivame and
rvumber ro a/.ro the f?8questor for guidelines on whose number to enter.
in the appropriate box. The TIN provided must match the name given on line 1 to avoid Social §®curtty number
Employer identmcatfon number
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am walting for a niimber to be issued to me); and
2. I am liot subject to backup withholding because: (a) I am exempt from backup withholding, or a) I have not been notifiecl by the lntemal Bevenue
Service OPS) that I am subject to backup wlthholding as a result of a fallure to report all interest or dividends, or (c) the lRS has notiflecl me that I am
no longer subject to backup wlthholdlng; and
3. I am a U.S. cltlzen or other U.S. person (dofined below); and
4. The FATCA code(s) entered on this form ¢f any) indicating that I am exempt from FATCA reporting is correct.
Certificatjon instructions. You must cross out item 2 above if you have been notified by the lRS that you are currently subject to backup withholding because
you have felled to report all interest and dividends on your tax retiim. For real estate transactions, Item 2 does not apply. For mortgage interest paid,acquisitlon or abandonment Of secured property, cancellation Of debt, contributions to an individual rotiremem arrangement ORA), and generally, payments
other than interest and dMdends, you ae not required to sign the certification. but you must provide your coi'rect TIN. See the instructions for Part 11, later.
Signature Of
U.S. p.rson +.ate, 1-l\-\q
General lns
Section references are to the Internal Plevenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, sucri as leglslatlon enacted
after they were published, go to in/`^/i^/./rs.gov/Fo/mw9.
Purpose of Form
An lndlvidual or entity (Form W-9 requester) who is required to file an
information return with the IF3S must obtain your correct taxpayer
identification number inN) which may be your social security number
(SSN), individual tab(payer identlflcat!on number (inN), adoptiontaxpayer identification number (A"N). or employer identificatlon number
(EIN), to report on an Information return the amount paid to you, or otheramount reportable on an information return. Examples Of information
returns include, but are not limited to, the following.
• Form 1099-lNT ¢nterest earned or paid)
• Form 1099-DIV (dividends, Including those from stocks or mutual
funds)
• Form 1099-MISC (various types Of income, prizes, awards, or gross
proceeds)
• Fom 1099-a (stock or mutual fund sales and certaln other
transactions by brokers)
• Fom 1099-S toroceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 thome mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person ¢ncluding a resident
alien), to provide your correct TIN.
If yeu. do not rctum Form W-9 to the requestor with a TIN, you might
be sufy.ecf to backup w/.tMo/dl.ng. See What ls backup withholding,
later.
Cat. No.10231X Fom W-9 03ev. 10-2018)
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