HomeMy WebLinkAboutRNDTBL_APP_W9.pdfDocuSign Envelope ID: 0563B605-15E0-4E7F-A330-3FC8406C49A8
DocuSign Envelope ID: 0563B605-15E0-4E7F-A330-3FC8406C49A8
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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 by the 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: _________________________________ Date: ______________
By signing this document, I attest that no event has occurred and no condition exists that is likely to result in
the debarment or 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 ☐ No ☐
If no, provide reason for denial: _______________________________________
If no, has notification been sent to applicant? Yes ☐ No ☐
Grant Payment Date: _____________________________________________________
City Representative Signature: _________________________Date: ___________
7/30/2020
DocuSign Envelope ID: 0563B605-15E0-4E7F-A330-3FC8406C49A8
7/31/2020
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DocuSign Envelope ID: 0563B605-15E0-4E7F-A330-3FC8406C49A8