HomeMy WebLinkAboutRDLION_APP_W9.pdfSMALL BUSINESS ASSISTANCE GRANT APPLICATION
Complete the fillable application in its entirety. Print the completed application,
sign and date and email, along with a copy of your W-9, to: OED2@-auburnwa:go'/.
Applications can also be mailed to the following: City of Auburn
Attn: Office of Economic Development
25 W Main
Auburn, WA 98001
TO BE COMPLETED BY APPLICANT
Name of Business: �� In� � Si'A\fe._s
CL C&J1) Name of Business Owner(s): �Cf' j)c.."j
Business Address: � lfi"' �f LY l,J r I t Av.l. ... n-. l,JG
City of Auburn Business License number: Bv� · 337,ABUS-33339
Expiration Date of Business License: 12 -3\-2.iJZQ
Contact Person Name and Title: :Q ' a,Yh1ol l t?.. ; -,
Contact Person E-mail: ""CA\'t t.. Q. S 1l"ie\ S . c...o <"'
Contact Person Phone: 2n -2..6, -C\n,}
(Optional) Is this business 51% minority-owned or women-owned (Y /N) _l__
Please initial each to confirm:
__ 10 or fewer employees
NC.. A for profit business in the City of Auburn established prior to January 1, 2020
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yl(_, Business has a physical presence (address) located within a commercial zone
within the City of Auburn. (Home based businesses do not qualify).
VJ(_ Business was adversely impacted by mandatory and/or voluntary business closures directly related to the public health response related to COVID-19
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 nondiscrimination laws and/or policies, including, but not limited to, the Americanswith Disabilities Act, the Civil Rights Act, and the Age Discrimination Act.•The Grantee affirms that residents, customers and/or employees are notdiscriminated against due to race, creed, color, religion, sex, national origin, ordisability.•In the event of the Grantee's noncompliance or refusal to comply with any nondiscrimination law or policy, this Agreement may be rescinded, cancelled, orterminated in whole or in part, and the Grantee may be declared ineligible forfurther agreements with the City.•In no event shall the City's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 theGrantee's failure to so comply with applicable law.•I bear full responsibility and understand that the Grant funds may be taxableincome; please consult with your financial advisor for guidance. A 1099 will beissued 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 relationshipcreated 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 activityor 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 vV-ith my signed application
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 D No □
Grant Payment Date: _______________________ _
City Representative Signature: ___________ Date: ____ _
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7/31/2020
X
Fonn W•9 (Rev Oc1ober 20181 Deoartment or lhe T re.1Sur/ lntema Reve,,ue Ser, ce
Request for Taxpayer
Identification Number and Certification
►Go to www.irs.gov/FormW9 for instructions and the latest information.
Name ,s required on lh1s ne. do not eave lh,s ,ne blank L 2 enl from abose
M � S�,� a, 3 Check appropnale box for federal tax class,ficat,on or the person whose name ,s enlered on :ine 1 g> following seven boxes
C: 0 • 1/) ., C:
0 lndiv1duaVso1e proprietor or single-member LLC D C Corporallon 0 S Corporation D Partnership
Check only one or the
D Trust/esta1e
Q. 0
; �
� l.Jm,ted hab,l1!y company Enter the lax class,r,cat1on (C,C corpora11on. S:S corporation, P:Partnersh1p) ► .SNote: Check the appropnale box n the line above for lhe lax class,ficallon of the single-member owner Do not check "g � LLC ,f the LLC 1s class,hed as a single-member LLC lhal ,s disregarded from 1he owner unless lhe owner or the LLC ,s
Give Form to the
requester. Do not
send to the IRS.
4 Exemptions /codes apply only to
certain ent1t1es. nol ,nd1v1duals see
,nstruct,ons on page 3)
Exempt payee code (11 any)_
Exempllon from FATCA reporting
code (,f any) It -_!:! another LLC lhat s not disregarded from the owner for U S federal tax purposes Otherwise. a single-member LLC thal ,s disregarded from the owner should check the appropnate box for the tax class1nca11on or ,ts owner g O Other(see nstruct10ns) ► �t0�l'TWf',�outs01NUS1
� fss"'.A.;d:;;d;;r;;:ess;;-;1;;:nu:::m::b;::-er:;-s;:;tr:;:e::e;-1.'=and=-:a=-p1=-=or=-s::u-.,1-:e-::no-:-) -;:::S-ee-,-n-,st-,nuc......,.t1-ons-------------..--R-eq_u _e-st _e _r'_s _na_m_e_J_and_::a:..d:.:d,..:re..:s:.:s:.:(o_p_11_ona-:Q:-------
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Taxpayer Identification Number (TIN)
Enter your TIN ,n the appropnate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For 1nd1v1duals. this Is generally your social secunty number (SSN). However, for a resident alien, sole propnetor, or disregarded entity. see the InstructIons for Part I, later. For other entities. 1t Is your employer 1dent1ficat1on number (EIN). If you do not have a number. see How to get a nN. later
Soc13I secunty number ITIJ -[D -I I I I I
or
Note: If the account is in more than one name, see the InstructIons for line 1 Also see What Name and Number To Give the Requester for guidelines on whose number to enter
Certification
Under penalties of perJury. I certify that:
1 The number shown on this form Is my correct taxpayer 1dent1ficat1on number (or I am waItIng for a number to be issued to me); and
2 I am not subject to backup w1thhold1ng because: (a) I am exempt from backup w1thhold1ng. or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or d1v1dends. or (c) the IRS has notified me that I am
no onger subject to backup withholding; and
3 I am a U S citizen or other U S. person (defined below); and
4 The FATCA code(s) entered on this form �f any) 1ndicat1ng that I am exempt from FATCA reporting Is correct.
Certification instructions. You must cross out item 2 above 1f you have been notified by the IRS that you are currently subIect to backup w1thhold1ng because
you have failed to report all interest and di111dends on your tax return. For real estate transactions. item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property ellation of debt. contnbutions to an individual ret1rement arrangement ORA). and generally. payments
other than interest and dividends. you are e ed to sign the cert1ficat1on. but you must provide your correct TIN. See the InstructIons for Part II. later
Sign
Here Signature of U.S. person►
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted
Future developments For the latest 1nformat1on about developments
related to Form W-9 and its nstructIons. such as leg1slat1on enacted after they were published. go to www ,rs.govlFormW9
Purpose of Form
Ar, 1nd1v1duaj or ent,ty (Form W-9 requester) who ,s required to file an
,nformatIon return with the IRS must obta,n your correct taxpayer 1dent1flcat1on number (TIN) which may be your social security number (SSN). 1nd,v1dual taxpayer 1denttficat1on number (mN). adopt,on
taxpayer 1dent1ficat,on number (ATIN). or employer ,dent1f1cat1on number (EIN). to report on an 1nformat,on return the amount paid to you. or other
amount reportable on an ,nformat,on return Examples of ,nformat,on returns include. but are not limited to. the follow,ng
, Form 1099-INT (interest earned or pa,d)
Cal No 1023tX
Date►
• Form 1099-DIV (d1v1dends, including those from stocks or mutual
funds)
• Form 1099-MISC (vanous types of income. pnzes. awards. or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest). 1098-E (student loan interest).
1098• T (tu1t1on)
• Form 1099-C (canceled debt)
• Form 1099-A (acqu1s1hon or abandonment of secured property)
Use Form W-9 only 1f you are a U S person (1ncludng a resident
ahen). to provide your correct TIN
If you do not return Form W-9 to the requester with a TTN. you might be sub1ect to backup w1thhold1ng See What •s backup withholding. later
Form W-9 (Rev t0-2018)
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City of Auburn
Small Business Recovery Grant Program
To mitigate the impact of COVI 0-19 on City of Auburn small businesses and their
employees, The City of Auburn Council has committed up to $650,000 in one-time funds to create a Small Business Assistance Grant Program. The objective of this
program is to offer immediate financial assistance to small businesses in the City of
Aub�m to aid in maintaining their business and workforce. Eligible grant recipients willreceive a grant award in the amount of $1,300.
After the initial funds are depleted, the City will retain applications received and track the
order in which they were received, as the City is hopeful it will be able to continue awarding grants if additional funds become available.
At a minimum businesses eligible to apply for grant funds from the City of
Auburn must meet the following criteria: •Business has a physical presence (address) located within a commercial zone withinthe City of Auburn. (Home based businesses do not qualify).
•Business is in good standing (including: current City of Auburn business license; currenton all State and regulatory requirements; not facing pending litigation or legal action,including Shoreline code enforcement).
•Be a for-profit business established prior to January 1, 2020.
•Have 10 or fewer employees (as indicated on your City of Auburn business licenseapplication).•Business was adversely impacted by mandatory and/or voluntary business closuresdirectly related to the public health response related to COVID-19. Have selected FoodService, Manufacturing, Retail, Wholesale or Other for "type" of business on your City ofAuburn business license application.
The City of Auburn has also determined that the following "types" of businesses
do not qualify:•Professional Services: Tax preparation and services, Attorney or legal services,
Accounting services, Bookkeeping services, Financial services or Environmental
services.•Retail: Convenience stores with gas stations, Pawn shops, Vehicle accessories sales,Landscape supply sales, online sales (as primary source of sales), Construction supplysales, Commercial or residential paint stores and drive through Coffee stands.•Automotive Services: Maintenance Shops, Car dealerships with maintenance/service
department, Automotive accessories sales or service, and Automotive paint shops.•Medical: Family physicians/doctors, Primary care, Dentists, Orthodontics, NaturalHealth doctors' offices and Veterinarians.•Food: Whole food sales and distribution.•Other: Distribution companies, Construction, Construction subcontractors andConstruction supplies and material sales.
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The City of Auburn reserves the right to change or modify the above referenced criteria
without notice. Based upon the aforementioned criteria above, if you believe your business qualifies for
the City of Auburn Business Assistance grant and you would like to apply for a grant
award, please download the Small Business Assistance Grant Application (PDF).
Application deadline is 5:00 PM (PST) August 15, 2020. Awards will be made on a first come, first served basis.
Contact Information
For further information or questions, please email: OED@auburnwa.gov
or call the Office of Economic Development at 253-804-3101.
Inquiries by email are highly encouraged because city staff has continuous access to
email. Due to shelter in place orders there is limited staff available at City Hall to
respond to phone inquiries -responses may be delayed
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